Report ,
982038
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PN W $ -AW W A ❑ EXISTING
BACKFLOW ASSEMBLY TEST REPORT , 0 REMOVED
PROPERTY ' =' ❑ REPLACEMENT
OWNER: Ii 1, —, f: - ,",'.J-, ,{ J PHONE:
MAILING t Y-: _
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ADDRESS: f ' ' `{ i 9,) ft,.: y 1 •:-. °e -r4 z
CITY ( rk.:FS.74.-'.. STATE T2 _ ZIP
ASSEMBLY .-
ADDRESS • tl ?' '
STREET
❑ R.P.B.A.'D D.C.V.A. ❑ R.P.D.A. ❑ D }} .C.D.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. ❑ AIR GAP
SIZE: 1 1 1.1 1 1 MAKE: I t (t t ip MODEL: 3 . -t±*,1 fi
WATER .-. ,
PURVEYOR: w f ( 9' ; 4 NUMBER: - ` = 1 `
ASSEMBLY ,f- t; r I
LOCATION: / I' : -API s° >_..
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REDUCED PRESSURE ASSEMBLY P.V.B.A. ) S.V.B.A. INITIAL TES ' 1
NI CHECK :I , IIEC AIR CHECK PASSED ,IS
PRESS DROP (A l CHECK #1,-1 INLET FAILED ❑ .
INITIAL RELIEF VALVE PR
I
TEST OPENED AT (B)IT IGHT ,1] OPENED AT. PRESS DROP
MIN 2 PSID `, ,`' PSID DATES -
M RESULTS BUFFER (LEAKED ❑ / ;
PSID PSID `
A - B = I CHECK #2 ,-2(
MIN 3 PST
RELIEF VALVE ITIGHT • m t . DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ 'LEAKED Li PSID OPEN ❑ Q PSI
.4
COMMENTS
REPAIRS
AND /OR
PARTS .
iii
xi
CHECK UCED PRESSURE ASSEMBLY AFTER REPAIRS
PRESS DROP (A) DATE: 1
TEST CHECK #1
RELIEF OPENED AT PRESS DROP
AFTER OPENED (8) I TIGHT ❑ PSID / /
REPAIRS Z D
Bt1F e R " CHECK #2
mama ITIGHT ❑ PSID PSID PSID PASSED ❑ _
IN COMPLETING AND SUBMITITNG THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WRH ALL.APPUCABLE
RULES AND REGULATIONS OF THE WATER. SYSTEM, AND STATE REGULATIONS.
`5 �
G AUGE CALIBRATION A 9?TE ¢ j _. — _ . - % : - D ETECTOR METER READING 19 :
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' TESTER SIGNATURE 3F t i t
TESTERS NAME PRINTS
° 'la-fa r t ro Olt r 11 f eaVel - 10 U R7 .(5fi f 3 R n GAUGE 1 i
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TESTERS ADDRESS
I - 'A:1"1i:1"! 1t,'Y.K ='I5 1 1ti. S Pi . i . i . .; � PHONE 1
COMPANY NAME
-