%PDF-1.6 % Sync information seamlessly and collect it anywhere you need it with a free online document handover form! Then you can enter the additional information about the counseling session, including the themes discussed, treatments, interventions techniques, summary and responses to the intervention. Whether for school or work, this form can be used to record personal information, incident details, and medical injuries. From now on comfortably get through it from home or at the office right from your mobile or desktop computer. Works on any device. Testing must be conducted by a certified tester upon installation and every 12 . The City of Oxnard Water Division is pleased to announce web-based Backflow Test reporting utilizing Tokay software. ' [Content_Types].xml ( N0EHC-j\X $@b/=>"RRQ{c%3X@LCV^i7 Sx[Ab7*@*HRf$g`E*} G;V )B~)K0{j17XdkVnrT[L! Enter costs, upload receipts, and more. This form can be embedded on any webpage which makes it easily available to anyone. Testers and customers can send any documents regarding backflow questions or issues to ATLbackflowoffice@atlantaga.gov. Find the extension in the Web Store and push, Click on the link to the document you want to design and select. Office: (919)-996-2747. Thank you for your patience as we continue to update our new website. 0000014015 00000 n Look through the instructions to learn which information you have to provide. While we don't test assemblies, we do keep a record of where backflow prevention assemblies are installed. Open the form in our online editing tool. Hydraulic Grade Line Request Form. Draw your signature or initials, place it in the corresponding field and save the changes. The signed test report should be submitted to DEP within 30 days of the installation of the device. 0 %%EOF Just customize the form questions to match your needs, then embed the form on your website or share it with a link. 40 0 obj <>stream gQXKW^-)mZ8}]k >%DdMXCzn 9iLDpo/N 7H2`$`Ko;Ajy6Np'A}x7S`k 4D`k"r#pA8$l/ PK ! Backflow is water flowing opposite of its intended direction, either from a loss of pressure in the supply lines or an increase in pressure on the customer's side. CCC Program Mgr. Be sure the details you fill in NEWWA Backflow Prevention Device Assembly Test Report Form is up-to-date and accurate. PSID 9?b,aFnF b==I. CLEANED ONLY Use this step-by-step guideline to complete the Get And Sign BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT CUSTOMER: ASSET #: SERVICE ADDRESS: ACCOUNT #: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RP DC MANUFACTURE: RELIEF VALVE PUB MODEL: CHECK VALVE #1 Line Pressure: SERIAL NO Form quickly and with idEval precision. The first part is for the Lead Medic or Battalion Chief to fill out. There are three variants; a typed, drawn or uploaded signature. Backflow Prevention Assembly Field Test and Maintenance Report Form Backflow Prevention and Cross Connection Control - CT.gov Under backflow conditions, unprotected cross-connections can introduce biological, chemical and/or physical contaminants into the drinking water. # Complete block and lot (if available) for New York City Metropolitan area tests. How to generate an electronic signature for the Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of online, How to make an signature for your Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of in Chrome, How to create an electronic signature for signing the Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of in Gmail, How to create an electronic signature for the Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of right from your smartphone, How to generate an signature for the Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of on iOS, How to generate an electronic signature for the Backflow Prevention Assembly Test And Maintenance Report Customer Asset Service Address Account Location Of Assembly Type Of on Android devices, If you believe that this page should be taken down, please follow our DMCA take down process, You have been successfully registeredinsignNow. New installations The T&M form must be printed and signed by a licensed tester who performed the work and a copy provided to BSI . A Weekly Shift Report is a form used by store owners or managers to track employee working days and hours in a week. Password: Repeat Password: Firm Name: Firm Address: Firm City: Firm State: Firm Zip: Firm Phone: 2021 Water Quality Report; 2021 Water Quality Report (Whipple) 2021 Annual Report; 2021 Financial Report; About Us. Backflow Assembly Test Report Send completed form and attachments to: backflow@tol.ca Premises name Premises address Postal code Owner's phone Owner's email Assembly location and hazard type Protection: Domestic Boiler feed Irrigation Sprinkler Other Assembly type: AG DCDA DCVA PVBA RPBA RPDA Notification # Manufacturer; Notification # Search. And because of its cross-platform nature, signNow can be used on any device, desktop computer or mobile phone, regardless of the operating system. A Covid-19 Acknowledgement is used by medical professionals to acknowledge patients that have consented to the Covid-19 vaccine. Open the email you received with the documents that need signing. Forms, Real Estate An asset disposal form is a form used to document the disposal process of assets. After testing is complete, your certified backflow tester will put your sticker labels on your report and mail the completed test report to us at: Portland Water Bureau DC. Backflow Assembly & Test Report Form Makes Managing Backflow Test Reports as Easy as 1, 2, 3 Forms currently available: All forms - $150 yearly - unlimited for up to 5 testers Submit Form to Agency You're DONE! trailer An employee timesheet template is used by employers to track the hours that their employees work. 0000013209 00000 n In addition to submitting the test report through SwiftComply, newly permitted assemblies (newly installed or replaced) shall be submitted to Building Inspectionprior to the inspection. Your testing notice will have a CCN (Customer Contact Number . Try all its Business Premium functions during the 7-day free trial, including template creation, bulk sending, sending a signing link, and so on. Backflow Information A+ A- Loading. Backflow Prevention / Cross-Connection Control Program. Gather all required reports with target questions thanks to the Illegal Fireworks Reporting Form. Easy to customize, integrate, and share online. The form can be printed and completed by hand, or 2. Great for travel agencies, airports, and airlines. Jotforms online report forms are fully customizable and completely free to use. When you employ this motor vehicle accident form template, youll be able to gather all of the information that you need. With your free Employee End of Day Report Form instantly collecting information online, youll have a cost-effective way to gather end of day reports from your employees no more messy paperwork or time-consuming daily meetings. It also detects the motivation behind mentioned incident and its consequence. PSID With Jotforms 100+ integrations, you can also store and analyze your Medical Report Form submissions with Google Drive. FChT-T38[KfKn-I-ANM^@nMlF_WSM;'OMf\?Duiu"zsi?YEy} CHECK VALVE: 295 Main Street Room 350 Buffalo, NY 14203-2494. To enroll, visit the SwiftComply portal at this address:www.bftester.com/dallastx, Request an Admin-style account where you can submit tests on behalf of testers in your company, Submit your Testing Certification and Test Kit Information (Please note these are required to sign up). Page 1. The USC (University of Southern California) Foundation's List of Approved Assemblies is a valuable resource of information. Motor vehicle accident form templates are important because theyre convenient and have preset questions ready to go. 503-823-4000 Traduccin e Interpretacin |Bin Dch v Thng Dch | | |Turjumaad iyo Fasiraad| | Traducere i interpretariat |Chiaku me Awewen Kapas | . Building, transportation, maintenance, and sewer projects. . PSID Otherwise, the tester may submit results for any backflow assembly test by using the Backflow Maintenance Report. There is a separate hidden section which gets emailed to the EMS Chief. Planning, Wills 10 31 With the Jotform builder, your report templates have access to widgets, apps, and themes to encourage engagement and improve the amount of information collected. Log in to your signNow account and open the template you need to sign. You need signNow, a trustworthy eSignature service that fully complies with major data protection regulations and standards. Forms 10/10, Features Set 10/10, Ease of Use 10/10, Customer Service 10/10. Free and easy to customize. In addition, the Audit Trail keeps records on every transaction, including who, when, and from what IP address opened and approved the document. If so, with this form, you can also prepare a service report includes this information and many more. A parking ticket form can be used by a traffic or parking officers that captured or caught a driver who illegally parked his or her vehicle. All completed Cross Connection Control/Water Protection forms (excluding Test and Maintenance Reports) should be submitted via email at awcrossconnection@austintexas.gov or mailed to: Austin Water, Special Services Division. No coding required. If you have any questions, please contact KC Water Backflow Division at 816-513-4795 or email at backflow@kcmo.org. View responses on any device. Opportunities posted to governmentjobs.com, Submitting backflow assembly test reports, City of Portland general information hotline, Backflow prevention and cross-connection control, state-certified contractor to test your assembly, Backflow assembly installation requirements, Legal and installation requirements for backflow protection. We provide commercial property owners an annual schedule for testing all their assemblies. Commercial buildings will have different types of backflow assemblies to protect our drinking water from a variety of uses, including fire sprinkler systems, irrigation systems, and water collection and reuse systems. Testers must be certified through the Ohio Department of Commerce and approved by Montgomery County Environmental Services to use the online system. Engineers Report For Approval Of Backflow Prevention Devices. I HEREBY CERTIFY THAT THE ABOVE BACKFLOW PREVENTION ASSEMBLY HAS BEEN IN CONSTANT USE AT THIS LOCATION. Use this template. xref Forms are available in PDF or Word format. CLARK COUNTY TEST AND MAINTENANCE REPORT BACKFLOW PREVENTION DEVICES FOR ALL OF CLARK COUNTY . Response: A: Device Size 1 1 1 2 3 4 6 Testing Unit Use professional pre-built templates to fill in and sign documents online faster. To help you properly complete the test report, we've numbered the fields on the sample test report and developed an instruction table. Create an account using your email or sign in via Google or Facebook. Decide on what kind of signature to create. Read the instructions to determine which details you have to provide. This form shall be used for backflow devices required under . If you would like to verify your next test due date, contact BSI at 800-414-4990 or the City of Durham's Cross Connection Program at 919-560-4194. 0000000016 00000 n 0000015936 00000 n People can report suspected cases of COVID-19 in their workplace or community. While we don't test assemblies, we do keep a record of where backflow prevention assemblies are installed. Portland, Oregon 972041926. Backflow/Cross Connection. An employee end of day report form is used to track employee progress and keep track of daily accomplishments. If you cant find an answer to your question, please dont hesitate to reach out to us. 0000005489 00000 n Theft, Personal For fee sheets, click here. PRESSURE B320 Optional fields appear cream shaded in the report and table. IT Service Request Form allows your customers to report an issue and make a request regarding a repair through providing their contact information, category of the problem, any further explanation and comments. CV ASSEMBLY Water Customers with a testable backflow assembly (s) will receive an initial testing notice two months prior to the test due date. To access the SwiftComply portal click the link below. A Departmental Report Form template useful for preparing daily reports regarding the department, internal issues and payroll through areas to fill/select/upload necessary information and documents with the manager contact information. Click on the fillable fields and include the required info. The signNow extension offers you a selection of features (merging PDFs, including multiple signers, and so on) for a better signing experience. Convert to official PDFs automatically. The form can be completed in one of two ways: The form can be printed and completed by hand, or If youre the plumber, the contractor wont need to contact every time you need to collect information. SubMenu3+ Annual Statistical Reports; Backflow Forms; Engineering Forms; Water Main Rehabilitation; CIP/IFR Program; Send the electronic form to the intended recipient. High-hazard backflow prevention assemblies must be tested annually by a licensed backflow tester. Browse the FAQs below to find more information on backflow devices, installation, testing and more. Frequently Asked Questions What is a cross-connection? Mailing your test reports will only take a few minutes. BACKFLOW PREVENTION. Utilize the, When you get a request from someone to eSign a document in signNow, you can easily do that without creating an account. We prefer that residential customers test their backflow assemblies in the spring before the summer irrigation season. Count all the cash&tips and enter it into the form, it will automatically calculate the totals for you. The week of November 21, 2022, SwiftComply sent letters to customers who are on record as owning a backflow device. Request these services online or call 503-823-4000, Relay Service:711. You must arrange to have your assembly or assemblies tested at least once a year. It is the responsibility of the company performing any RBA related work to complete and submit a RBA Test Report with appropriate payment to the City within two weeks of work . Spanish, Localized Get a dedicated support team with Jotform Enterprise. All can be achieved without coding! A workplace harassment complaint form is used to document workplace harassment complaints. There will be a $10 fee to submit tests through the SwiftComply portal. 0000041487 00000 n %PDF-1.6 % LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RP. BACKFLOW DEVICE TEST REPORT FORM. Design and Construction Standards for Wastewater Collection Systems. Create an account with signNow to legally eSign your templates. Double-check each and every area has been filled in properly. Customize this free template without coding! A SEO business report form is a report template used by webmasters to gather information about SEO techniques, tools, and related metrics used by online businesses. PSID This report should help backflow assembly testers (BATs) and water systems comply with the minimum test report content requirements in the Operator Certification Rule. Try one of our free online report form templates today! Backflow Certified Test Report Banner Operating Certificate Driveway Fence Impact Fee Irrigation Meter Downsize Permit Application Signs Swimming Pool Temporary Activity/Structure(Tent) Residential Driveway Fence Garage Sale Impact Fee Irrigation Meter Downsize Permit Application Swimming Pool . hb```f`````ufb@ ! The form will just need information such as reason for violation, amount of fine, date, driver's license number, time, location, license plate number, driver's name and name of issuing officer. Jotform is a fully customized, easy-to-use Form Builder that includes changing, adding, or removing fields through the drag and drop function, and changing the colors, fonts, and background without any coding required. This program is in accordance with Ordinance #95-21 and Florida Administrative Code 62-555.360. We'll mail you a reminder letter each year with sticker labels to give to your backflow tester. This is an essential part to help them develop their skills and business capabilities. 0000004918 00000 n The device must be approved by the State Water Resources Control Board. 1120 SW 5th Avenue, Bldg. We are making improvements on each form. 0000001149 00000 n REPLACED: Select the appropriate Laboratory Evaluation Report Form (LERF) or Factory Audit Inspection Test Report Form (FAITRF) from the menus below to request your ASSE report form. After that, your backflow test report is ready. This test form can be used to streamline the test and maintenance process. Because of the ever changing nature of the building and construction industry, together with the continuing development of new technology and . Select the Sign button and make an electronic signature. 275 Merton St. Toronto, ON M4S 1A7. Guarantees that a business meets BBB accreditation standards in the US and Canada. <]/Prev 57040>> Laboratory Evaluation Report Forms LERF's are designed to guide laboratories in evaluating products submitted for certification. Form DOH-1013, Report on Test and Maintenance of Backflow Prevention Device. CLOSED TIGHT Example - Site Plan Drawing. An accident report form is a record of an accident or incident, used to provide the details of the accident to insurance companies. Here is a list of the most common customer questions. This protection is achieved through the installation of backflow devices or assemblies after each . If you do not own a backflow device and mistakenly received a letter, please disregard it. With this cash up sheet template, you can easily prepare daily/nightly cash up reports for your company. Having a proper inventory of your ingredients helps maintain a buffer on the movement of your items, replenished in due time and thus reduces the risk that might affect the productivity or your business. We Recommend using the Chrome Browser on all devices for backflowtestreport.com Links BSI Online Tracking SC Tracking Solutions startxref The first-aid provider can complete the form with their own contact information and e-signature, and use the included Glasgow Coma Scale in the event of a head injury. If not an annual Test, please select one of the following: New Assembly Remove Assembly Replace Assembly. The City of DallasWater Utilities has established a cross connection control and backflow prevention program to ensure water quality. Check Valve 1. 0000003835 00000 n To become an approved backflow prevention assembly tester within the City, you must provide to BSI Online proof of commission licensing and proof that your testing equipment can maintain calibration of plus or minus 0.2 psid accuracy.. Backflow Prevention Assembly Tester (BPAT) license and gauge calibration certification must be submitted and maintained before any backflow test reports will be . f?3-]T2j),l0/%b Report expenses for employees at your company. SHUT OFF VALVE You can get documents for every purpose in the signNow forms library. Be sure to keep a copy of the form for yourself, and mail the form to: City of Davis Public Works Utilities & Operations Department Attn: Backflow 1717 Fifth Street Davis, CA 95616. Receive submissions for COVID-19 test reports from your staff for your company or organization online. Fee Schedule. General Instructions The purpose of form TCEQ-20700 Backflow Prevention Assembly Test and Maintenance Report (T&M Form) is to document the results of testing a backflow prevention assembly. Backflow Prevention Assembly Test Report Return Legible and Satisfactory Reports to: WATER UTILITY AUTHORITY - COMPLIANCE DIVISION CROSS CONNECTION CONTROL OFFICE - SOUTHSIDE WATER RECLAMATION PLANT P.O. If this form template meets your expectation, then just use this complaint form template and even manage it as you wish. Get your online template and fill it in using progressive features. Technology, Power of CLOSED TIGHT After all, you don't really need all the details in many circumstances. endstream endobj startxref A medical report form is a document used by medical professionals for documenting a patients medical treatment. Thank You. Sync with 100+ apps. Annual Reports; Board of Directors; Did You Know? Backflow Prevention Assembly Test Report 701 South Miami Street West Milton, Ohio 45383-1339 Phone: 937.698.1500 www.westmiltonohio.gov Fax: 937.698.3900 Go to My Forms and delete an existing form or upgrade your account to increase your form limit. Check Valve 2. This Police Incident Report template is used to provide the police with notifications about an incident or matter that are considered to be non-urgent. This is a report form for the fire modifications. For more information about the program please contact us on backflow@watercorporation.com.au or call 13 13 95. A daily shift report form is used for businesses that manage their workforce through shift reports. Administrative Office. phone (305) 547 miami-dade water & sewer department meter opertations & maintenance cross-connection control unit 1001 n.w. REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE PART A - To Be Completed by Certified Tester # Indicate the test year and whether initial or annual test. The plumber will need to test to ensure that the pipes are properly installed and not leaking. Check Valve 1. CV ASSEMBLY Just customize the Medical Report Form to match your practice add your logo and colors, and easily add more form fields. Access the most extensive library of templates available. The backflow test form is an evaluation tool that is used to evaluate a building's plumbing and equipment. With this volunteer fire department incident report template, you can find a volunteer firefighter. As of November 14, 2022, the City of Dallas moved to an online feature that allows testers to submit backflow test reports through SwiftComply. Testing is only required if an irrigation backflow device is newly installed, repaired or replaced. Fax: (919)-996-1865 E-mail: cross.connection@raleighnc.gov Website: www.raleighnc.gov crossconnection.raleighnc.gov Service Address: 0000008931 00000 n Link the form with your Slack workspace to quickly inform others of the injury, or integrate it with Google Sheets or Airtable to keep all data in one place. This sample report includes several optional fields that commonly appear on other test reports used in Washington. A COVID-19 compliance report form is used by healthcare facilities to provide information about compliance with the COVID-19 vaccine for patients. Clone one of our productivity reports templates and start customizing it based on your business needs. A standard IT Service Form, useful for businesses that deal with everyday IT related tasks which can be used as an IT service ticket template that allows file attachment and provides an area for further information. Important: Test reports will not be processed if they do not have the Water Bureau-provided sticker label on them. Follow the step-by-step instructions below to design your backflow test form: Select the document you want to sign and click Upload. Currently the City of Dallas does not require annual inspections of backflow devices installed on irrigation systems such as lawn sprinkler systems. No matter which way you choose, your forms will be legally binding. The form can be completed in one of two ways: 1. We appreciate all of the Backflow Testers that have used our Software for many years. The only thing worse than dealing with an incident? All backflow test results must be submitted through the Online Backflow Test Entry System. 11th street, miami, fl 33136-2209 -3046 fax (786)268 5485 This form is used to submit both initial and annual test results for backflow prevention device(s). LLC, Internet STATE FORM 55788, BACKFLOW DEVICE TEST 327 IAC 8-10-9(b) TYPE OR PRINT ALL ENTRIES. Whether its a complaint, incident or bug, giving one a proper way to report is pretty important. h[qW8"#,'?%}GO>wU[g`JtM>*6+_[upXgr+;R= c~.D\CJO1lWuB+7$W~EM Cts!1!/K-sfH[o*VT ~_!c1t,9V!gPc v( GPL`UJ,0f"bu3c\4C5hj- nd3*d0NEw)#EZ5,=o]F~MFg)0Ux1d~_} FLh\qL>%262,ct q~VTMVtUJi)S-M2Le9$000&aD1z6/!&e%2.+.\-T&o]=}to?I#@>WO/~O^k=.>]ON^V|zr%ezC#?NlyL#gY?~VF?~:T|QE_T|QE_R|I%_R|I%OV. a private or public potable water source shall be connected to the water source through a reduced pressure principle backflow prevention assembly as defined in 344.50 of this title (relating to Backflow Prevention Methods); and . Bavco Backflow Apparatus & Valve Co. For Watts and Duke Test Kits 20435 South Suzanna Rd Long Beach, CA 90810 800-458-3492. By using this template, the citizens can report the incident with the informations such as date and time when the incident occurred, incident location, incident details, contact information. I certify that the information provided in this Backflow Incident Report is complete and accurate to the best of my knowledge. Examine the completed document for misprints as well as other errors. Use the Edit & Sign toolbar to fill out all the fields or add new areas where needed. A void items record form is used by businesses to document when items are returned to them by customers. Job log form provides you with the job title, staff name, and date with each of the tasks that are accomplished, their start and end time, work description, materials that are used in the process, and the files related to the job. The signNow extension was developed to help busy people like you to reduce the stress of signing legal forms. I would like to be added to the list of Certified Backflow Testers. There will be a $10 fee to submit tests through the SwiftComply portal. Mechanical Joint Restraint . The Cross Connection Program is responsible for ensuring potable water provided by the City remains safe throughout the water distribution system and is protected from "backflow events." (an undesirable reversal of potentially contaminated water from a customer to the City's system.). = M word/document.xml}nHT2$=nZel^q[SK6.xoHYv:x8q\EO;p"x$?:'n0ua?y? The construction site will have several pipes that carry water, waste, or both. We have recently fixed the date issue with the Pasadena Form. Speed up your businesss document workflow by creating the professional online forms and legally-binding electronic signatures. The new software will increase on-time backflow tests, improve compliance and reduce administrative delays.