Report OCT -15- 2010 15:18
FLAvi 2010 —00 3 2zi-
P.002
� . J 0 9 ( 1 sin/ i ' C-1
W 47727
KNEW
BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED
PROPERTY - 0 REPLACEMENT
OWNER: 0 .c� ¢,...t % PI{ONE
MAILING
ADDRESS: ___t Ct L S ( ( t
CITY 1 1 1 04-44.. STATE r ZIP i 7 ZZ Ti
ASSEMBLY
ADDRESS: ,5 r4-4e
STREET
D R.L'.B.A. ® D.C.V.A. ❑ R.P.D.A. D D.C.D.A. Q P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. ❑ AIR GAY
SIZE: 1 U D MAKE: Walls MODEL 00 W1 ( t `h'
WATER ---- r SERIAL
PURVEYOR: rc 1 c_ 1e � -� , NUMBER; 3 R' 1 o e) 3
ASSEMBLY
LOCATION: '(Al) d s[.._... GI _ L rJ ..4
— .Y__.. _ REDUCED PRESSURE ASSEMBLY P,V.B.A. / 511.13.A. INITIAL. TEST -
#1 CHECK DOUBLE CHECK AIR CHECK PASSED .
PRESS DROP (A) CHECK 8I INLET FAILED ❑
INITIAL RELIEF VALVE OPENED AT; PRESS DROP
OPENED AT CB! TIGHT
TEST MIN 2 PO
LEAKED ❑ psiD DATE:
RESULTS BUEHR
A - B - CHECK 42
PSID PO /0 / l 3 / it)
MIN 3 PSI
RELIEF VALVE TIGHT ko / w J DID NOT FAILED SYSTEM �y
PASS ❑ FAIL ❑ LEAKED ❑ P SI D OPEN PSID ❑ PSI _, Fib
COMMENTS
REPAIRS
AND / OR
PARTS
REDUCED PRESSURE. ASSEMAIN P.V.R.A, / S.V.R,A AFTER REPAIRS
#1 CHECK D.C,V.A
TEST PRESS DROP tAl, CHECK 41 OPENED AT MESS DROP DATE:
AFTER OPENED D IB) ; TIGHT ❑ - PSID /
REPAIRS BUFFER MIN : PSID i CHECK 42
A - R = _ -- PASSED ❑
MIN 3 PSI !TIGHT ❑ PSID ^P51D PSIU
IN C.O MPU.TE•.ING AND SI.IRMITFING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY IIAS BEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGIRAnnNS OF THE WATER SYSTEM, AND STATE REGIAATIONS.
GAUGE CALIBRATION DATE / / a /it, D r CTOR METER READING _
_ , �' 4 7
' TESTER SIGNA7VRE
} Fw h PS Q,2-o4
� t to GA
Q ^ 701'3 I -0
TESTERS ADDRESS S , J � b . ��8
�?. _ i �' ` D _ J] �Ce ekt6 a jl
COMPANY NAME 1 /JF; /�j((�G- f✓ !/ PHONE Y
REPORT MENU/ RV: IREPRESENTATh E OF OWNER) 5TRVICE RESTORED
WHITE . WATER SYSTEM COPY PINK - CUSTOMER COPY YELLOW - TESTER COPY
E✓
1
•
4-
TOTAL P.002