WebBackflow Prevention Device Test Form MUST BE COMPLETED BY CERTIFIED BACKFLOW DEVICE TESTER Please return completed form by mail or fax to Pennsylvania American Water: Fax: 570-341-3296; Email: [email protected]; or Mail: Attention: Cross Connection Department 2699 Stafford Ave Scranton, PA 18505 WebBackflow Assembly Information - Please Print Serial Number: Model: Size: ... *Use only Manufacturers replacement parts / **Test records must be kept on file for at least 3 years. Date Tested for Accuracy Manufacturer: ... The following form must be completed for each assembly tested. A signed and dated original must be submitted to the
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Test Maintenance Backflow Prevention Assembly Report Form
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