Permit Support Document Accurate Backflow Testing
BACKFLOW ASSEMBLY TEST REPORT ❑NEW
P.O.Box 157• Forest Grove,OR 97116 ❑EXISTING
503-357-1444• CCB#235735 ❑REMOVED
PROPERTY ❑REPLACEMENT
OWNER: PHONE:
MAILING
ADDRESS:
I CITY ASSEMBLL.� C / STATE ZIP
ADD ESSY 1S S�7 I Jw /C�G����
STREET
❑R.P.B.A, 0 D.C.V.A 0 R.P.D.A. ❑D.C.D.A. ❑P.V.B.A. ❑S.V.B.A ❑A.V.B. ❑AIR GAP
SIZE: 1 I 1.1 I I MAKE: MODEL:
WATER SERIAL.
PURVEYOR: NUMBER:
ASSEMBLY
LOCATION:
REDUCED PRESSURE ASSEMBLY P.V.B.A t S.V.B.A INITIAL AST
rCHECK
(Ali DOUBLE CHECK. AIR CHECK PASSED-
PRESSCHECK tl INLET FAILED CI
INITIAL RBLIEF VALVE
TEST OPENED wT (B)ITIGIIT ❑ OPENED AT PRESS DROP DATE:
RESULTS
Mu:2 PSIDLEAKED 0 PSID
CHECK PSID PSID
'TIGHT ❑'` t DID NOT FAILED SYSTEM
RELIEF VALVE Psrf OPEN ❑ ❑ PSI
PASS 0 FAIL ❑ 'LEAKED❑
COMMENTS
REPAIRS
AND/OR
PARTS
REDUCED PRESSURE ASSEMBLY P,V,B,AiS,V.B.A. AFTER REPAIRS
I CHECK In.V.A.
TEST PRESS DROP
AIICHECK #1 DATE:
RELIEF OPENED AT PRESS DROP
AFTER OPENED 03) TIGHT ❑ PSID• J
REPAIRS BUFFER �,rm
CHECK t12
A-e_ ITIGHT 0 PSID PSID PSID PASSED 0
ro
IN COMPLETING AND SUBMITTING THIS TEST REPORT,TIIE TESTER.CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WTTI ALL APPLICABLE
RULES AND REGULATIONS OE THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATION DATE ' f DETECTOR METER READING
194759
'ASTER SIGNATURE Alex Vanderkin - CERT a
TESTERS NAME PRINTED P.O.Box 157 • Purest Grove,OR 97116 GAUGE 0
503-357-1444
TESTERS ADDRESS Accurate Backflow PHONE
COMPANY NAME
SERVICE RESTORED ON
REPORT RECEIVED BY (REPRESENTATIVE OF OWNER)
SERVICE RESTORED OFF
WRITE-Water System Copy PINK•Customer Copy YELLOW-Testa Copy