Report PLM I/ - 0 5 &6
X NEW
BACKFLOW ASSEMBLY TEST REPORT gill EXISTING
0 REMOVED
_. PROPERTY REPLACED
- OWNER: 1?i ! ci 4.tt c 4 0 PHONE:
MAILING !� � . A
ADDRESS: Gi `
„ 4 5 ld F t".
i
CITY ! - t G7 ).• I STATE 0 ZIP
ASSEMBLY
ADDRESS (.51 641 -p
, 0 R.P.B A y{,D.0 V.A ® R.P D.A. ® D.C.p.A. D P V.B A. ® S V.B.A. ® A.V.B. ® AIR GAP -
SIZE: II MAKE: IV ' /4' , zj MODEL: { )
WATER SERIAL
PURVEYOR r j y - NUMBER: 5 6
ASSEMBLY ! t
LOCATION. - ,°'to S r cy vi, - _ 4ri'life 1.4,1 et S
F F
i
REDUCED PRES URE ASSEMBLY - P.V.B.A. / S.V.B.A. INITIAL T T
#1 Check DOUBLE,CHECK ' AIR CHECK PASSED '
Press. Drop - Check. # 1 INLET
INITIAL ReliefValve Tight,, 7 Opened at: Press Drop FAILED ii
TEST Opened at: -
RESULTS mm 2 psi Leaked i - 's1,:V Date: -
BUFFER
A _ g = . Check # 2 � psid psid i / / 7 / t1f
mm 3 psi � °�
RELIEF VALVE Tight , - -DID NOT FAILED-
SYSTEM
PASS �y FAIL F' Leaked'® psid OPEN - PSI /415::--
I 4
Comments
Repairs
and/or
Parts
i i
Reduced Pressure Assembl . _A Doub l e,1Check 4 P -V B A. / S.V.B.A. " • AFTER REPAIRS
TEST
Check #1 !Check # 1
AFTER Press. Drop Tight ® Opened at: Press. Drop Date*
Relief psid
REPAIRS Opened
min 2 psi ' ®
Check # 2
Buffer 'Tight Q psid psid psid PASSED
'
A - B= min 1nsi ^^
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
A regulations of the water system. and state regulations.
GAUGE CAL4BV TfON DATE 02 -11 -11 DETECTOR METER READING
TESTER SIGNRUR V CERT it 1129
TESTER NAMRINTE/ GENE HIGGINS GAUGE # 1189
' TESTER ADDRESS BRUSH PRAIRIE WA ccs # 127076
COMPANY NAME Gene Higgins BAT PHONE # 503 - 780 -3823
SERVICE RESTORED
REPORT RECEIVED BY (REPRESENTATIVE OF OWNER)