American Society of Sanitary Engineering
901 Canterbury Road, Suite A, Westlake, OH 44145
Phone: 440-835-3040 Fax: 440-835-3488
Website:www.asse-plumbing.org
Email:
PROPERTY OWNER PERMISSION LETTER
Application #: Date:
(assigned by ASSE)
Instructions for Completing This Form
This form shall be completed and submitted to ASSE with the application for test site form.
Evaluation Site Address:
Assembly Information
Type: RP RPDA DC DCDA
Manufacturer:
Model #:
Size:
¼” 3/8” ½” ¾” 1” 1 ½” 2”
3” 4” 6” 8” 10” 12”
Orientation:
Horizontal Vertical Flow Up Vertical Flow Down
Vertical Up/Vertical Down Vertical Up/Vertical Up
I, the undersigned property owner of the proposed field evaluation test site as listed above, do herby grant the ASSE and/or subcontracted tester of ASSE the right to test the backflow assembly on my property.
I acknowledge agreement to the following:
1) The device will be tested nominally once per month to ensure compliance to the applicable ASSE backflow standard. Fire protection assemblies will be tested quarterly.
2) Once initiated, the evaluation period will last for a minimum of one year.
3) Water service will be interrupted from ten minutes (usual) to up to one hour (unusual) during the periodic tests. For sites requiring uninterrupted water service, a bypass line equipped with a second backflow assembly of the same type installed.
4) Only an ASSE subcontracted tester will be permitted to inspect, test or repair the device during the entire evaluation period.
5) Unrestricted access to the installation site will be allowed to the ASSE subcontracted tester (for the purpose of inspection, test or repair only).
6) Upon successful completion of the field evaluation test, the manufacturer of the backflow assembly will transfer ownership of the assembly at no charge.
7) Should the device on test fail, it is the manufacturer’s responsibility to replace it with another approved backflow assembly at no charge.
Property Owner Name: Email:
Signature: ______Phone Number:
Manufacturer: Email:
Signature: ______Phone Number:
CC: ASSE
Manufacturer
Property Owner
G:\Product Listing Program\One Year Field Test\Binder Contents\Forms\Property Owner Permission Letter.doc- POPL 07/14/2009