Report (2) 4f9, ' z
[XX] WATER PURVEYOR (ICJ WENT [ fa] FILE 1058E-66039
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CI Ekistlng
Backflow Assembly Test Report O RR:Z7 eot
PmPo,h.O,Ier.MODERN PLUMBING Phone(503)691-6166
Melling Ahbe..!11120 INDUSTRIAL WAY
CityTUALATIN state OR bP 97062
i AesemblyMd,eu: 9500 SW GREENBURG RD.,PORTLAND, OR 97223
1 ❑R.P.B.A IE D.C.V.A. ❑R.P.D.A, ❑D.C.D.A. ❑P.V.B.A. ❑S.V.B.A. ❑AV B. ❑AIR GAP
i I 1 P 1 SIZE: 4 MAKE: WATTS MODEL: 757
WP: TV WATER 046- SERIAL NUMBER: WJ-2238
ASSY LOCATION:RIGHT OF ENTRANCE TO DEVELOPMENT IN VAULT ❑A MPERS SWITCHES
REDUCED PRESSURE ASSEMBLY P.V.B.A.I S.V.B.A. INITIAL TEST
) al CHECK DOUBLE-CHECK AIR CHECK [ PASS
PRESS DROP (A) CHECK CI INLET
i INITIAL (� PRESSURE ❑FAIL
TEST RELIEF VALVE TIGHT "f�-S OPENED AT DROP
RESULTS OPENED AT (B) tLEAKED PSI DATE:
BUFFER 11/20/23
1 A-S CHECK d2 ? 2 PSID PSID
RELIEF VALVE TGHT 3+ s SYSTEM
j ❑PASS CI FAIL 0 LEAKED PSI OPEDIDN NOT ❑ FAILED ❑ PSJ —
1 COMMENTS
I REPAIRS
I AND/OR
PARTS [A J DOWNSTREAM INJECTION PORT PRESENT (B 1 SUPPLY SIDE GRAIN PRESENT
I C J#1 SHUT OFF UNUSABLE-MUST USE MAIN SHUT OFF!DJ 112 VALVE UNUSABLE
[E J SUBMERGED CONDITION [F J El SHUT OFF LEAKS BY.MUST USE BYPASS
REDUCED PRESSURE ASSEMBLY
Al CHECK DOU9[f.GHECR P.V.B.A.I S.V.B.A.
TEST PRESS DROP (A) CHECK#1 AFTER REPAIRS
j AFTER ❑TIGHT OPENED AT PRESSURE DATE:
RELIEF VALVE DROP
REPAIRS OPENED AT (B) PSI
CHECK 02
BUFFER
A-B 0 TIGHT PSI PSID P510 PASSED CI
IN COMPLETING AND SUBMITTING THIS TEST REPORT.THE TESTER CERTIFIES THAT THE
1 ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE DETECTOR METER
1 RI II FS AND RFGUTA]IONS OF TH ATER SYSTEM,AND STATE REGULATIONS READINCI
GAU NO.
TEETER SIGNATURE CERT k [ f}04070711(A)[ [04142149(B)
I GREG DOUGLAS 2708 CALIBRATION DATE
TESTER NAME PRINTED [X]02/13/2023
14 P.D. Box 808 TUALATIN OR 97062
I TESTER ADDRESS PHONES (503)692-2885
i CERTIFIED TESTER FOR: BAICKFLOW CCB TIME
PREVENTION DEVICE TESTING, 167327 : E01t
I COMPANY NAME LEFT AS FOUND
;
abn Shut Off / Shut or*1 snit off II 2 :. ERVICE RESTORED
On Q Off Q)On 0 Off t On Q Off WINTERIZED