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Report - /HEATH Pc. N a o �o ov 3c 9 BACKFLOW KFLOW 32236 ❑ NEW ❑ • E XISTING BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED PROPERTY l ❑ REPLACEMENT OWNER: �° PHONE: ADDRESS: / (1 9 S / w/ 7Gt CITY 7%,- STATE //`'`— ZIP q72 ASSEMBLY ADDRESS: STREET ❑ R.P.B.A.,i 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: I I / j.(.$ir MAKE: IL,/ /e/i+/J MODEL: 9'6) £1 � WATER SERIAL PURVEYOR: / ! �Irs l/` ., NUMBER: �0 R: .� 2 lS 9 y ' ASSEMBLY ;PIP LOCATION: .t 2 / YYGV 7- -,T' - ' / REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST NI CHECK ( DOUBLE CHECK AIR CHECK PASSE ° ' © PRESS DROP (A) CHECK #1 INLET FAILED ❑ INITIAL RELIEF VALVE TEST • OPENED AT (B)ITIGHT P OPENED AT: PRESS DROP DATE: MIN 2 PSID !LEAKED ❑ PM) Mfg-04 RESULTS BUFFER PSID PSID A - B = I CHECK #2 MIN 3 PSI RELIEF VALVE (TIGHT 0 /' / DID NOT FAILED SYSTEM • PASS ❑ FAIL y ❑ !LEAKED ❑ PsD OPEN ❑ ❑ PSI COMMENTS L' ` t�1■ CJ V`L!i' De I or 1 5 ! l' 7 "l ,4 / c'' , 1.e REPAIRS AND /OR PARTS REDUCED PRESSURE ASSEMBLY P. V.B.A. /S.V.B. A. AFTER REPAIRS NI CHECK D.C.V. A. PRESS DROP (A) DATE: TEST RELIEF I CHECK #1 OPENED AT PRESS DROP AFTER OPENED (B) TIGHT ❑ PSID / / REPAIRS BUFFER '®3 ° � I CHECK #2 A -B= ,°a ITIGHT ❑ PSID PSID P510 PASSED ❑ m q 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 3/ / 0 � DETECTOR METER READING ��` e - .. 3275 TESTER SIGNATURE David B Heath O, ? /t),1 T _ ` TESTERS NAME PRINTED PO Box 1565 Sherwood OR 97140 (5O3) 625 8 TESTERS ADDRESS Heath Backflow Inc. PHONE.N COMPANY NAME C SERVICE RESTORED D REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) 1 WHITE - Water System Copy PINK • Customer Copy YELLOW - Tester Copy