Report Z7
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WoterM¢fricsWest
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BACKFLOW ASSEMBLY
TEST REPORT NEw
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PROPERTY •
OWNER: va PH
MAILING
ADDRESS: 7 41 1 :w`°,N C soar a' e st
CITY () ga' d- STATE °P ZIP .iy
ASSEMBLY
ADDRESS: 710. ' I. e+ arm} cr ea SI:. T board
STREET
— 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: t `..- ± r \:1 .S MODEL: '`', C. -
WATER SERIAL • 1
PURVEYOR: T L Pr,H (" irt�;r nil • NUMBER: `�" -ti z..7 ‹ ` .•
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ASSEMBLY
LOCATION: nt.,' rri &Lt it `,,v
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
#1 CHECK - DOUBLE CHECK AIR CHECK PASSED'
PRESS DROP (A) INLET FAILED —
RELIEF VALVE CHECK #1 • W S IAL OPENED AT MIN z PSID (R) TIGHT r2 y OPENED AT: PRESS DROP
BUFFER LEAKED • PSID DATE: `
RESULTS< A B PSID PSID 1 ' ' ( ` •
MIN 3 PSI CHECK •#2
RELIEF VALVE TIGHT = ,' DID NOT FAILED SYSTEM I'
j PASS FAIL LEAKED — PSID OPEN — — PSI
. COMMENTS
REPAIRS
AND /OR
PARTS _
REDUCED PRESSURE ASSEMBLY 9••° P.V.B.A. / S.V.B.A. AFTER REPAIRS <>
#1 CHECK I D.C.V.A
TEST PRESS DROP (A) CHECK #1 . - OPENED AT PRESS DROP DATE:
AFTER OPENED (B) TIGHT _ PSID
REPAIRS BUFFER MIN 2 PSID CHECK #2
A - B = PASSED
MIN 3 PSI TIGHT PSID PSID PSID
IN COMPLETEING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE `�j
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATIO N DATE _f 1a:rTx:,CJlv)t DETECTOR METER READING
TESTER SIGNATURE .---- - i_ : - - _ ° - - CERT # • Q,
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TESTERS NAME PRINTED GAUGE #
16120 SW'72ND, PORTLAND, 97224 (503) 603 -9988
TESTERS ADDRESS • PHONE #
WATER METRICS CO. WEST
COMPANY NAME WWW.WATERMETRICS.COM
❑ SERVICE RESTORED
REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)
WHITE - WATER CM - FM envy MAW _ rnr7ne.1r1 r..n:, m.. ...