Report . 35132
r NEW
BACKFLOW ASSEMBLY TEST REPORT El REMOVED
PROPERTY A ❑REMOVED
OWNER: 14 -- sgy REPLACEMENT
MAILING ADDRESS: �7 PHONE 9 2 0 74 (�,.� ®.�
ADDRESS: 1/ / 01 .5~ ej -3 i t ( 1 e,
/� 9 4
( ASSEMBLY CITY / r STATE 0 ZIP 7 7 .1-1 / c
RJ �.,y�,
4 ADDRESS: 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: ® '.1 MAKE: (A) E I YY-1.5 MODEL: g/St) X L_-__.
WATER
P
SERIAL URVEYOR: I f yid LA, r'1 44"‹. NUMBER: "� 6� 7
(J\ LOCA IELY LOCATION: Y 144 --4.. .-&"/.. ( \£x ° \ - ` -. 1 - G 'k--r-r--
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
#1 CHECK CHECK AIR CHECK PASSED A
PRESS DROP (A) INLET
VALVE CHECK #1 FAILED ❑
INITIAL OPENED AT (B) TIGHT OPENED AT: PRESS DROP
TEST MIN 2 PSID
RESULTS BUFFER LEAKED ❑ PSID DATE:
A — B =
MIN 3 PSI CHECK #2 PSID PSID � /1 4 //1____
RELIEF VALVE TIGHT DK ,' DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ LEAKED El pSm OPEN ❑ ❑ PSI /0.5
COMMENTS
REPAIRS
AND / OR
PARTS
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. AFTER REPAIRS
#1 CHECK D.C.V.A
TEST PRESS DROP (A) DATE:
AFTER RELIEF CHECK #1 OPENED AT PRESS DROP
REPAIRS OPENED (B) TIGHT El PSID a / /
BUFFER MIN 2 PSI - „ ,a )
CHECK #2
A — B =
MW 3 PSI TIGHT ❑ PSID pg(p PSID • . PASSED ❑ ,
IN COMPLETEING 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 REGULATIONS.
GAUGE CALIBRATION DATE /P/ /1 REA
DETECTO TER D
i .2 7 - _ ::,
TESTER SIGNATURE q CER # " }
TESTERS N'�} TE r C7 `� C E /
6 p /1 GA GE #. .
TESTERS ADDRESS � �h
PHONE # "
COMPANY NAME
REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) El SERVICE RESTORED
WHITE - WATER SYSTEM COPY PINK - CUSTOMER COPY YELLOW - TESTER COPY
•