Report `NEW.
4® • ❑ EXISTING !
'PNWS AWWA s i BACKFLOW-ASSEMBLY TESTREPO R OREMOVED I
.;-
:PROPRTY x O' REPLACEMENT .j
OWNER ) - T: PHONE , 1
MAILING : . - -a, "- -
ADDRESS: k ,i ' .. l
1 'CITY � - ,
i - - •_ , .. STATE'
. t - ▪ ZIP — i
• i ASSEMBLY
-_ ADDRESS: - - - .
STREET ,- -. .
• DR.P.B.A,0 D.C:V.A.'laR.P.DA. D. DCD.A; ❑ P.V.BA. OSVB.A. ❑,A:V.B. GAP. .I
SIZE: 1- I 1 �`. d. . MAKE: "q. �,:., v . `•, =- s ..
WATER MODEL: ,
SERIAL
' PURVEYOR: 1 4 =•,s :.." - . .. NUMBER 'i a. .: -
ASSEMBLY , • 1. • '
• LOCATION• { "1:�. _ )
REDUCED PRESSURE ASSEMBLY - P V.B.A. / S V.B,A. INITIAL
NI CHECK
yE Ij !SIR CHECK PASSED ❑
PRESS:DROP -- CHECK ` #T y EO INLET ^:• F AILED :❑ • , "
1 - INITIAL RELIEF VALVE
TEST OPE AT B
{ )ITIGHT li r .; •? CIPEN Ar. PRESS" DROP _ D A TE ' . ' 1
RESULTS BUFFER_ MIN 2 PSID - !LEAKED Cr -PSI° PSJD PSID { •
i _I . .CHECK . #2 ge t '
MIN 7 PSI N.,' ,
• RELIEF VALUE - ITIGHT ,, ® _'`; DID NOT FAILED SYSTEM . ` j
PASS C -,FAIL ' ❑ ILEAKED.❑ PSID > 'OPEN ❑ ❑ PSI .
i
•
COMMENTS
f -, ` REPAIRS -
AND IS • I
PARTS "
4.
y kPCHECK REDUCED PRESSURE ASSEMBLY P V.B.A /S V.B AFTER REPAIRS
r; - (A) ¢ , N . A. _. :DATE:
" T PRESS,'OROP - RELIEF. CHECK #1
- OPENED 'AT PR D ROP
AFTER OPENED - (8) I TIGHT DROP - .kip / / 1
• - REPAIRS BUFFER iip
ICHECK #2
_" Kamm " ITIGHT ❑; PSID PSID PSTD PASSED ❑
IN COMPLETING AND SUBMITTING' THIS TEST - REPORT, THE TESTER CERTIFIES THAT_THE -
" ASSEMBLY`HAS BEEN.TESTED MAINfAINED ACCORDANCE WITH ALL .APPLICABLE i
RULES AND REGULATIONS.: OF THE, WATER SYSTEM, AND -STATE REGULATIONS - ' -: I
!
GAUGE .CALIBRATION, -DATE "� / > '"'DETECTOR METER READING 4.
TESTER (SIGNATURE CERTB> .
r
TESTERS NAME PRIrITE[ e�# pTL 3 G I N
TESTERS ADDRESS " . 7 4. , Eta L w1:7 GM ,-X •.. !..1 1 3
I t+ PHONE B ,
1 COMPANY. NAME ti- Lt; .L �;�? i. .i' , _ l _ v .111-0—a.... - -- -- — .1.:______...:_.a..