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Report /HEATH P.MA0l0 - - . - r BACKFLOW INC. 32255 ❑ NEW ❑'EXISTING BACKFLOW ASSEMBLY TEST REPORT REMOVED 5 PROPERTY f �� `� ��// ❑ REPLACEMENT -. OWNER: 4 ('/tA 4 '7 5 ✓ * ,' ,. 9473 PHONE: ; MAILING ADDRESS: / 5 e, 5" 5 ti./ ✓4,0 ro t V/e i i I- CITY 7 STATE ae ZIP 4 4- ASSEMBLY j ADDRESS: STREET ❑ R.P.B.A. / Er D.C.V.A. ❑ R.P.D.A. ❑ D.CC.D.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V .. B. ❑ AIR GAP L SIZE: I 1 MAKE: /., /> /l ref MODEL: 7 J PURVEYOR: 7 / � NUMBER: J ' Q f "4 5 ASSEMBLY A LOCATION: (/I'7' C t/ )/"i / <_u�y r / y REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST ill CHECK I DOUBLE CHECK AIR CHECK PASSED e PRESS DROP (A) CHECK #1 INLET FAILED ❑ INITIAL OPENED AT (B)ITIGHT / a' 2. c OPENED AT: PRESS DROP TEST MIN 2 PSID DATE: �f RESULTS ( I LEAKED ❑ PSID PSID PSID 11 DATE: `� `0 BUFFER A - B = I CHECK #2 MIN 3 PSI RELIEF VALVE 'TIGHT Cr). _ DID NOT FAILED SYSTEM I PASS ❑ FAIL ❑ LEAKED❑ PSID OPEN ❑ ❑ PSI COMMENTS /' REPAIRS / c � ( 0 / AND /OR 6 ! - 1 PARTS REDUCED PRESSURE ASSEMBLY P.V.B.A./S.V.B.A. AFTER REPAIRS MI CHECK D.C. A. TEST PRESS DROP (A) V. CHECK #1 DATE: RELIEF I OPENED AT PRESS DROP AFTER OPENED (B) TIGHT ❑ PSID i REPAIRS bia$1°SED BUFFER ( CHECK #2 ' A -B= PASSED ❑ .mr.v ( TIGHT ❑ PSID PSID PSID 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 0 THE WATER SYSTEM, AND STATE REGULATIONS. GAUGE CALIBRATION DATE °I/C//"DETECTOR METER READING � � 3275 TESTER SIGNATURE David B Heath 4` `�l CERT TESTERS NAME PRINTED PO Box 1565 Sherwood OR 97140. , , (503) 625-8553 TESTERS ADDRESS PHONE Heath Backflow Inc. COMPANY NAME © SERVICE RESTORED t REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) ( WHITE - Water System Copy PINK • Customer Copy YELLOW • Tester Copy