Report BACKFLOW ASSEMBLY TEST REPORT . ❑ E Xl s n"G
❑ REMOVED
I PROPERTY ❑ REPLACED
OWNER: r-t h (114.1 .5 !A A e PHONE: • MAILING f f C ,, 7
ADDRESS: f 1 9 z, f 'lI 7 ` - / '
0.4
CITY 7/ 7 q N G• STATE f ZIP
ASSEMBLY
ADDRESS j
.. q «C°
❑R.P.B.A. (/0D.C.V.A ❑R.P.D.A. ❑D.d. .A. ❑ P.V.B.A. E] S.V.B.A. ❑A.V.B. ❑AIR GAP
'/ 00
SIZE: �... MAKE: V(/ Q' f MODEL: 0 07
WATER LI 1/1../d N ERI
, NUMBL BER: 4 ‘41. 7 /
PURVEYOR 7 UM
I ASSEMBLY
• i LOCATION: C G2 I'll 1 - * . _ . T k : 0 K r r Pf/ ,. ' . Y e I
4 REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
#1 Check DOUBLE CHECK AIR CHECK
PASSED
Ch k #
Press. Drop INLET
�
INITIAL ReliefValve Tight i 2. Opened at: Press. Drop FAILED ❑
• TEST Opened at: Id D te:
• CS—% • RESULTS BUFFER
min. 2psi Leaked n psid � f {I �1
A _ B = Ch k # 2 psid psid �/ /
• min. 3 psi
Tight 2. I
RELIEF VALVE DID NOT FAILED SYSTEM ;j
.\1°C I PASS n FAIL n Leaked ❑ psid OPEN f1 _ n PSI
' Comments T �4 r ( Tc.- , U % ,J •
and/or
Parts
• Reduced Pressure Assembl Double Check P.V.B.A. / S.V.B.A. AFTER REPAIRS - Lt
Check # 1 C
TEST Press. Drop 'Check # 1 Opened at: Press. Drop Date: Th
AFTER Night ❑ psid
I REPAIRS erred
• p min. 2 psi ' Check # 2
Buffer ( Tight El psid psid psid PASSED ❑
B=
1 A - min 9 nci
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 regulafions
GAUGE CALIB TION DATE 03-01 -2008 DETECTOR METER READING
TESTER SIGNm,RE / ' '.,' CERT 0 1129
TESTER NAME PRtMTEe i ' GENE HIGGINS GAUGE 0 1189
TESTER RESS : ' BRUSH PRAIRIE WA CCB 0 127076
COMPANY NAME A&A Drilling, Clackamas OR PHONE 0 503 - 2843701
N SERVICE RESTORE D
REPORT RECEIVED 9Y: 'REPRESENTATIVE OE OWNER' ^ r
} Pa e 1 of 1 ,
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