Report (72) Backflow mow:_ `" - _' -= _ -2051907370
7Zb!/p-etsg Ale caar� ❑
/�,� Assembly 9 � NEW
90
iy Test Report THIMINO s IIIIIVidati �Q ___ ❑EXISTING
`k-kQU� - o \1 ( a- Y' x _....- t'E`t-k„ _......,,.- .� I r1 t r ii ❑ REMOVED
Portland.S r•Seattle
Property ❑ REPLACEMENT
Owner: Residence_.m..__._._ _....� _K Phone:
Mailing Address: ___, __.nx. ,. .a, ,. .,.:,_.... _ : .___n .a_._ ,_4 _,_ -,�:„_.�<:,
lob Address: 14068 SW 118th CT Tigard OR 97224
❑RPBA []RPDA ❑RPDAII ❑DCVA ❑DCDA ❑DCDAII ❑PVB ❑SVB ❑AVB ❑AG
Water Purveyor: Tigard_m _A,_,:__ Serial Number: W,e :,
Location: •
,.,..-...-.., --. ,x ..,m,..:.. ,.._,.. s.w______ ..
Make:
Assembly Service: _ ❑ Locked ❑ Alarmed
Approved: LI Assembly A V LI Instalation {]Orientation
REDUCED PRESSUREASSEMBLY P.V.B.A S.V.B.A INITIAL TEST
#1 CHECK I DOME CtEM . AIR INLET CHECK PASSED ❑
PRESSURE CHECK#1 Type U L FAILED ❑
INIITAL DROP MIN 5 PSID i TIGHT ❑ OPENED AT: PRESS DROP DATE:
i t,. i PASS ❑ FAIL ❑ IMinimum / /
I LEAKED ❑ 1 PS0
RESULTS RELIEF VALVE PSIHECK#2 OPENED
PSID STs t tM
OPENED AT PSI
i TIGHT ❑ FULLY ❑ F QD DETECTOR MTR
MIN 2 PSID
Minimum DID
PASS n FAIL 1-1I LEAKED ❑ 1 PS1Q NOT ❑
#1 Shut Off
�REPMAIRS '❑ Handle
AND/OR . . i RtJsteti Off
PARTS
' #2 Shut Off
#1 Shut Off Found 17N ( OFF"Up Stream Shut Off Found D ❑OFF ❑ Handle
#2 Shut Off Found DON ❑OFF i Service Restored to Found State ❑ i Rusted Off
REDUCED PRESSURE ASpEMY P.V.B.A/S.V.B.A AFTER REPAIRS
#1 CHECK ( DOUIRECHECX DATE:
i tS I PRESS DROP 'CHECK#1
AFTERTIGHT ❑ PSID OPENED AT: PRESS DROP / /
REPAIRS RELIEF VALVE I
OPEDED (CHECK#2 PSID PSID PASSED ❑
AT I TIGHT ❑ PSID
GAUGE* 20940 Make/Model Midwest 845 CALIBRATION DATE 5-7-17
In completing and submitting this test report,the tester certifies that the assembly was tested and maintained in accordance with all
applicable rules,laws,codes and regulations of the state and water system using approved testing equipment and testing procedures.
B5750 _
TESTERS SIGNATURE Washington CERT#
Josh Blacker 5313
TESTERS PRINTED NAME Oregon CERT#
American Backflow Services
5905 N Interstate Ave,Portland,OR 97217 (877)950-2468