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Report PM Backflow 10- 104634 MI NEW (503) 830 -0171 El EXISTING ❑ REMOVED BACKFLOW ASSEMBLY TEST REPORT ❑ REPLACEMENT PROPERTY OWNER: National Safety Co, Inc. /L 1 2OOf - f QO 3'2 9 Phone: (503) 841 - 2410 MAILING ADDRESS: 17010 SW Weir Rd , CITY, STATE, ZIP Beaverton, OR 97007 ASSEMBLY ADDRESS: 7095 SW Gonzaga St, Tigard, OR 97223 n R.P.B.A. ❑ 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: (. .. MAKE: 4_2 5 MODEL: O© 7 Q r WATER SERIAL PURVEYOR: TVWD NUMBER: 3 3ce/ 7 ASSEMBLY �/ LOCATION: Pie -L.: rc., / . oa ,1.-z INITIAL REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST CHECK #1 I DOUBLE CHECK TEST PRESS DROP o (A) CHECKS AIR INLET CHECK PASSED RESULTS RELIEF VALVE , O (B) TIGHT LJ FAILED El AT OPENED AT: PRESS DROP BUFFER MIN 2 PSID LEAKED ❑ PSID DATE: A - B E CHECK #2 09 -02 -2010 MIN 3 PSID PSID PSID RELIEF VALV TIGHT SYSTEM ,/ PASS FAIL ❑ LEAKED ❑ PSID O ENOT [—I FAILED ❑ PSIJ COMMENTS REPAIRS AND / OR PARTS REDUCED PRESSURE ASSEMBLY I D.C.V.A. P.V.B.A. / S.V.B AFTER REPAIRS TEST CHECK #1 PRESS DROP (A) I CHECK #1 PSID OPENED AT: PRESS DROP DATE: AFTER RELIEF VALVE I TIGHT [1] OPENED AT (B) REPAIRS BUFFER MIN 2 PSID P SID CHECK #2 PASSED A B MIN 3 PSID I TIGHT ❑ 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 OF THE WATER SYSTEM, AND STATE REGULATIONS. GAUGE CALIBRATION DATE: 01 -07 -2010 DETECTOR METER READING 7 4101 TESTER SIGNATURE CERT # Paul A. Molisani 04071586 TESTERS NAME PRINTED GAUGE # PO Box 981 Wilsonville, OR 97070 (503)830 -0171 TESTERS ADDRESS PHONE # PM Backflow COMPANY NAME SERVICE �RE RED REPORT (REPRESENTATIVE YES I� NO El BY: ( E OF PM Backflow 10- 104635 MI NEW (503) 830 -0171 ❑ EXISTING ❑ REMOVED BACKFLOW ASSEMBLY TEST REPORT ❑ REPLACEMENT PROPERTY OWNER: National Safety Co, Inc. , i o09 -6 9 Phone: (503) 841 -2410 MAILING ADDRESS: 17010 SW Weir Rd , CITY, STATE, ZIP Beaverton, OR 97007 ASSEMBLY ADDRESS: 7095 SW Gonzaga St, Tigard, OR 97223 ❑ R.P.B.A. ❑ D.C.V.A ❑ R.P.D.A. MI D.C.D.A ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. ❑ AIR GAP SIZE: u MAKE: ( 7 MODEL: 3 613 ^l l'C' WATER SERIAL PURVEYOR: TVWD NUMBER: 3 ` 67(3' ASSEMBLY �' /� LOCATION: / - :f e f r�sc- /- 6 t 0A-z S , se INITIAL REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST CHECK #1 I DOUBLE CHECK PASSED , TEST PRESS DROP (A) CHECK #2 AIR INLET CHECK FAILED ❑ RELIEF VALVE TIGHT I� OPENED AT OPENED AT: PRESS DROP El (B) BUFFER MIN 2 PSID LEAKED II] PSID DATE: A - B = CHECK #� 09 -02 -2010 L MIN 3 PSID TIGHT L� RELIEF VALVE ( p PSID PSID SYSTEM PASS ❑ FAIL El LEAKED El PSID OPEN�T ❑ FAILED ❑ PSI /C's COMMENTS REPAIRS AND / OR PARTS REDUCED PRESSURE ASSEMBLY I D.C.V.A. P.V.B.A. / S.V.B.A AFTER REPAIRS TEST CHECK #1 PRESS DROP (A) I CHECK #1 PSID OPENED AT: PRESS DROP DATE: AFTER RELIEF VALVE I TIGHT ❑ OPENED AT (B) REPAIRS BUFFER MIN 2 PSID I P SID CHECK #2 PASSED A - B MIN 3 PSID I TIGHT ❑ 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 OF THE WATER SYSTEM, AND STATE REGULATIONS. GAUGE CALIBRATION DATE: 01 -07 -2010 DETECTOR METER READING 000c>, o cs � ,7 4101 TESTER SIGNATURE CERT # Paul A. Molisani 04071586 TESTERS NAME PRINTED GAUGE # PO Box 981 Wilsonville, OR 97070 (503)830 -0171 TESTERS ADDRESS PHONE # PM Backflow COMPANY NAME SERVICE RO ❑ RESTORED REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) YES N PM Backflow 10- 104636 tu NEW (503) 830 -0171 ❑ EXISTING ❑ REMOVED BACKFLOW ASSEMBLY TEST REPORT ❑ REPLACEMENT PROPERTY OWNER: National Safety Co, Inc ,L� A009 DD 3 .9 Phon (503) 841 MAILING ADDRESS: 17010 SW Weir Rd , CITY, STATE, ZIP Beaverton, OR 97007 ASSEMBLY ADDRESS: 7095 SW Gonzaga St, Tigard, OR 97223 ❑ R.P.B.A. ❑ D.C.V.A ❑ R.P.D.A. 0 D.C.D.A ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. LI AIR GAP SIZE: 0. ? MAKE: An, e MODEL: a 70©01i'!'f3 WATER SERIAL PURVEYOR: TVWD NUMBER: / 00 C- ASSEMBLY /J LOCATION: F t;s �� . - o�r Q , 5'0 u7 // 5( e INITIAL REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST/ CHECK #1 I DOUBLE CHECK Q / TEST PRESS DROP (A) CHECK AIR INLET CHECK PASSED RESULTS RELIEF VALVE TIGHT FAILED ❑ (B) OPENED AT OPENED AT: PRESS DROP BUFFER MIN 2 PSID LEAKED ❑ PSID DATE: 09 -02 -2010 A - B = MIN 3 PSID CHECK 3 ^ , /' PSID PSID TIGHT RELIEF VALVE ©' OtJ /y DID NOT SYSTEM PASS El FAIL ❑ LEAKED ❑ PSID OPEN ❑ FAILED ❑ psi /Oa COMMENTS REPAIRS AND / OR PARTS REDUCED PRESSURE ASSEMBLY D P.V.B.A. / S.V.B AFTER REPAIRS TEST CHECK #1 PRESS DROP (A) I CHECK #1 PSID OPENED AT: PRESS DROP DATE: AFTER RELIEF VALVE I TIGHT LI OPENED AT (B) REPAIRS BUFFER MIN 2 PSID P SID CHECK #2 PASSED A B MIN 3 PSID I TIGHT El PSID PSID El 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: 01 -07 -2010 DETECTOR METER READING DO O C. 0 0 � 4101 TESTER SIGNATURE CERT # Paul A. Molisani 04071586 TESTERS NAME PRINTED GAUGE # PO Box 981 Wilsonville, OR 97070 (503)830 -0171 TESTERS ADDRESS PHONE # PM Backflow COMPANY NAME SERVICE R NO LI RESTORED YES J REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)