Report r . ,;,'
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--11 NEW PERMIT #:
BACKFLOW ASSEMBLY TEST REPORT
0 EXISTING DATE ISSUED: 21
0 REMOVED .
PROPERTY ,— / - 0 REPLACEMENT D
OWNER: / 4 Z:.-f.....4. f safne2: P. f l'e: PHONE
MAILIN yen,/ '7,-,
ADDRESS: G i - - t." -5 *:- e:e. 2 j4// / . . / - fZ. 7 . . ' ( 00 AM PAGE: '1
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CITY - 1 1 7 , -</f,.../...1"' STATE ' zly (722 ? 3
ASSEMBLY , ' -:„...., 1 CLASS OF WORK:
ADDRESS: - - , e-> , - ,,, - - I TYPE OF USE:
.,-- STREET
.„." .
0 R.P.B.A: ,a1 D.C.V.A. 0 R.P.D.A. El D.C.D.A. CI P.V.B.A. Ei S 0 A.V.B. El AIR GAP ' ! •
./ ., - tter0 .
SIZE: i ./ 6 : MAKE: ,i-. 4,.,.. . MODEL
WATER - t • I') _._ N SE umB RIAL : ./.
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PURVEYOR: „ 4 ei- 7 ..,.. .-m-' - PHONE #:
ASSEMBLY
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1 PHONE #: 971. 22
LOCATION: e-S' en .A....------- k /
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REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST i Pour Time:
#1 CHECK DOUBLE CHECK AIR CHECK PASSED' a .-- 1
.--,
PRESS DROP (A)
CHECK #1 INLET . . FAILED 0 • 1 # Message
REUEF VALVE
IN (B) TIGHT .,Er e., ' I
MAL OPENED AT OPENED AT: PRESS DROP '1
TEST MIN . 2 PSID
LEAKED 0 pSID • DATE: . : 6 N
RESULTS BUFFER _ 1
A - B = PSID PSID E2 g /..`:.7" ' 1
MIN 3 PSI CHECKi2
i
RELIEF VALVE , TIGHT / 4iil ' /2 DID NOT FAILED SYSTEM
• PASS 0 FAIL 0 LEAKED 0 PSID OPEN
I
COMMENTS
REPAIRS
AND/OR 1
1
PARTS 1
i •
REDUCED PRESSURE ASSEMBLY ' P.V.B.A. / S.V.B.A. AFTER REPAIRS i
#1 CHECK D.C.VA DATE:
TEST PRESS DROP (A)
CHECK #1 OPENED AT PRESS DROP
AFTER RELIEF 0 PSID / / I
(B) TIGHT OPENED i
REPAIRS .....,
BUFFER/
MIN 2 PSID
CHECK #2 • •
..:...- .- .. A ,•).= " MIN 3 PSI TIGHT 0 Pao PSID PSID PASSED 0 1 .
, IN COMPLETEING AND SUBMITEiNG THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
. ( 1 j. 1/t OSSEMBSIHAS BEEN TESTP}JANIL IN ACCORDANCE WITH ALL APPLICABLE . , I4 - i
i . i" KULES AND REGULAU FI ONS O lit WATER SYSTEM, AND STATE REGULATIONS. ,
. '
I , „. ....
GAUGE CALIBRATION DATE </._7% /' re'r DETECTOR t.6
TOR METER READING I ')
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TESTER SIGNATURE , ,,_„,,...s- - 7, -- ,...„ CERT #
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e - -/--.)--- ..--‘>' '•.'-.::,' 2-i,S"7/ ' /.:.)51_,
TESTERS NAME PRINTED f - GAUGE # '
/ 2" / ■''... _ — /...;-‘ e _ 4"?...' ..-:.- — ,..-, . ..'"; fT <'''' :77-;13 /.. 5?-7efi•,
TESTERS ADDRESS . i •'‹ '" - s t'r J-) i r - -- PHONE 4 ' I
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COMPANY NAME " - - .
El SERVICE RESTORED
REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)
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WHITE - WATER SYSTEM COPY . PINK- CUSTOMER COPY YELLOW - TESTER COPY
/ I.)
. . . . .. .
•
p 1 pi PARTIAL APPROVAL n CANCEL 1 1 NO ACCESS
n FAIL 1 1 CALL FOR INSPECTION n ADDITIONAL FEES ASSESSED
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Inspector: Date: 70 )-3 / 1° 1 Phone #: (503) 718-(4(76)-19