Report 4 HEATH - 23757
INC. BACKFLOW -
IN �D•NE -W
❑ EXISTING
. BACKFLOW ASSEMBLY" TEST. REPORT O REMOVED .
PROPERTY r 0 REPLACEMENT
OWNER: / e: »O Ln/.,/P�/ _ PHONE:
MAILING / 72 /
ADDRESS: . 1 2 ) 0 . / S .C L✓ /�l� / )1 J -
CITY / -c t' L- STATE ��(�. ZIP �/ 7� ' 7 5
ASSEMBLY V -
ADDRESS : - -
STREET
❑R.P.B.A. O D.C.V.A. ❑ R.P.D.A. ❑ D.CC.DD..A. ❑ P.V.B.A- ❑ S.V.B.A: ❑ A.V.B. ❑ AIR GAP
SIZE: s 1 1 "1 I'I MAKE: LA/ 1 .-,--/ .-,--/ 5 MODEL: 7' U
'WATER SERIAL
PURVEYOR: cq„ ✓C �/ ._ NUMBER: 3 O - 7 J 6
ASSEMBLY U
LOCATION: /5"-,- 2 / a�
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST
MI CHECK ' DOUBLE CHECK AIR CHECK PASSED. -
PRESSDROP (A) CHECK #1 INLET _ FAILED ❑
INITIAL RELIEF VALVE
OPENED (B) TIGHT ❑ OPENED AT PRESS DR
TEST ( ( DATE:
MIN 2 PSID . PSID
RESULTS BUFFER (LEAKED ❑ i27�
' PSID`" � - -. PSID
A - B CHECK #2"
MIN ,3 PSI I
TIGHT _•_ DID NOT FAILED SYSTEM •
RELIEF VALVE ❑ qq PSID OPEN ❑ ❑" PSI
PASS ❑ FAIL ❑ !LEAKED ❑
COMMENTS
REPAIRS
AND /OR •
PARTS .
•
REDUCED P.RESSUREASSEMBLY P.V.B.A. /S.V,B.A. AFTER REPAIRS
MI CHECK ...
PRESS DROP ( ^)� b DC'.V A DATE:
TEST CHECK` #1
RELIEF I OPENED AT PRESS DROP
AFTER OPENED (B) TIGHT ❑ PSID /
REPAIRS BUFFER ' 2'_ MD I CHECK #2
A - e = YIN 1PSt I TIGHT ❑ PSID PSID • PSID PASSED ❑
IN COMPLETING AND SUBMITTING THIS TEST REPORT. THE TESTER CERTIFIES'THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED: IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE- WATER SYSTEM. AND STATE REGULATIONS
GAUGE CALIBRATION DATE 12 P (DETECTORR METER READING
// — z _ _--- 3275 .
TESTER SIGNATURE "
David .B Heath _ 20039 / ----
TESTERS NAME PRIMED PO Box 1565 Sherwood OR, 9 (503 625-8553
TESTERS ADDRESS PHONE N
Heath Backflow -Inc.
COMPANY NAME - -
❑ SERVICE RESTORED
REPORT RECEIVED BY: (REPRESENTATIVE'OF OWNER)
WHITE - Water System Copy PINK - Customer. Copy YELLOW - •Tester Copy