Report /204 7o22 - c)y0
Oregon
Ba kflow
fry,
BACKFLOW EXISTING —REMOVED
PREVENTER REPORT 111111 NEW REPLACED
REPAIRED OLD SIN:
PROPERTY NAME Creekscape Design LLC PHONE 503-539-5388
CONTACT NAME Juan Gutierrez Segovia PHONE
MAILING ADDRESS 3065 SW 178th Ave
city Beaverton STATE OR zip 97006
PREVENTER ADDRESS 14044 SW Walnut Ln Tigard, OR 97223
WATER SUPPLIER Tigard SERIAL# HG17194
LOCATION By meter in beauty strip by hydrant
MAKE Febco MODEL 850 SIZE 1"
TYPE n RP 0 RPDA ❑ iu'DA-Ii [X] DC ❑ DCDA ® DCDA-I[ I I PVB SVB AVB ❑ AG
HAZARD PROTECTED III PRBMISISISOU9TON n IRRIGATION ® FIRE SYSTEM I I BOILER OTHER
APPROVED: lX ASSEMBLY 0 INSTALLATION ixjORIENTATION El AIRGAP PIPE SIZE in SP OON in
REDUCED PRESSURE ASSEMBLY PVBA/SVBA INITIAL TEST
DOUBLE CHECK AIR INLET C[iECE VALVE PASSED X
CHECK#1 CHECK#1 TYPE III OPENED AT: PRESS DROP:.
PRESS
o TIGHT lX (AILED II
INITIAL MIN S PSID 2.5
TEST RELIEF VALVE LEAKED n MN I PSI) .aN i run NON 1 PSID DATE 11-02-22
RESULTS OPENED AT: OPENED
ADE 2 PSm CHECK in FULLY EI FAILED SYSTEM rsi 54
RELIEF VALVE: TIGHT ® DID NOT I I DETECTOR METER
PASSED n FAUX) 2.7 oErnt4 I READING:
LEAKED ❑ PAD11 Ps®
NOTES
REPAIRS
PARTS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA TEST
CHECK#1 DOUBLE CHECK AFTER REPAIRS
PRESS
DROP: _ CHECK#I TYPED ri AIR INLET CHECK VALVE
REPAIR MIN 5 MID TIGHT I OPENED AT: PRESS DROP:
RESULTS RELIEF VALVE DATE
OPSNED A1: CHECK#2 ININ I PSG) NM I MID MIN I MD
Rta.1N VM V5 MIN 2 PSID TIGHT ❑ I
OPENED El
PASSED [
Turn„
PAAR1u) ❑ FAILED fI i,n FWD
GAUGES/N 02AC21090173 MAKE/MODEL Mako MK5 CALIBRATION DATE 08-29-2022
In completing and submitting this test report,the tester certifies that the assembly was tested and maintained in accordance with all applicable
rules,laws,codes and regulations of the stale and water system using approved testing equipment and approved testing procedures.
INITIAL TEST TEST AFTER REPAIRS
6422
TPS SIGNATURE TESTER SIGNATURE TESTER CERT#
Steve Reid 503-491-9402
TESTER NAME(PRINTED) TESTER NAME(PRINTED) PHONE#
PO Box 230113 Tigard, OR 97281 deanna@obtllc.com
TESTER ADDRESS t els I ER ADDRESS EMAIL
Oregon Backflow Testing, LLC
COMPANY NAME COMPANY NAME WATER RESTORED?
7FOLRVD OFF,LEFT OFF
REPORT RECEIVED BY(ti}iPRL NTATIVE OF OWNER) REPORT RRCRIVEDBY(REPRESRNTATOVE OF OWNER