ReportIlk
E E
OCT 3 2017
CITY Of- €i'':,;,-'/',,,-if''.
r L -µfp
1» .` :.
�
0 NEW
BACKFLOW ASSEMBLY TEST REPORT 0 EXISTING
ID REMOVED
PROPERTY 1 RE PL CEt�� iii I'
(i6 1 EIt:_L
L 1 LLFIIG-_...__. � .4_ "'es`` t.:._ PIIONE ,ft''').1:'.-7S 3O
CI'I S STATE 'Cirt ZIP_ _i
ASSEMBLY r_ - ,�t`° ' # .off .. ':�.. .
ADDRESS: ..Fm_t.x
� STREET
I'`-R,P,B.A. 0 D C t.A. ❑ R P.D,1. E.3 l)C D A. ® P.V.B A 0 S V B.A. 0 A.V.B. 0 AIR GAP
a
MAKE:, '4 ODEL: C d
WATER I I R 1 ,/ "Po��[41, ILIAL
PURV I,YOR: ''" f1 v-4 I � NUMBER:
ASSENIBLY LOCATION: +i !'-I .,_. GVI0vSr tA,, , I t /I", "" ? 1/... J" V /t• _
REDUCED PRESSURE ASSEMBLY PA%1LA /S.V.B S INF HAL TEST
z,-1 CHECi ��VVIR CIII CR PASSED
PRESS DROP 1 }' CHECK H I INLET FAILED C
RED1 4EtIINITIAL Al ..�: I �(Hi:
TIGHT
WEND)AEPRESS DROP
TESTi[w ili ,
tLEAKED d Psili® DATE
RESULTS IIITEIII ___.__ ._
1 I3= ) --., CHECK_: P4EI) i}5Ii) _..
itt4$PS! y
R:1111 1 AE��E: ;IIGin DIE NOTS FAE!W) SYSTEMPASS FAIL i LEAKED PSEE) PSI
COMMENTS �I J ' F 4r
y� E
REPAIRS "
PAR"I"S
il£nt VI 1)I LD ASx,tat..LS' Mr) P.V.B.A.1 S.t.Ii.:. BVI'I ER REPAIRS
m1 CEiI.CK I)"C,A'.A DATE:
'rEsT PRESS DROP (A) (a`ii'.{.' #i ibin]Sti)AT Num mow
AFTER RELEE,f' £ ,'` 1(11 I J P l-F— ' _ 7 j
REPAIRS LITER
ISi.Ii w££ti t P£CCS it t�EIE:CR "?
i _ ) ' PASSED Li
TIGII"i E_1 R. ND Psnt
IN( '',t;I)`11ro;AM)SLT11li\ IIBS IiVI-£E!'t)It'9,iEt£_TI.c('I'RCIFti1££IiSIli VI101
ASSP)II§£1`HAS BUN 103 LI):100,'1.110I AIN]D IN 111"0110IM II t}'I'IYI AIt,APPLICABLE
RI1LS 100 LIIIl,110 .1 d 1r 00;Lift,;`:§'S€1'1.10011'sn.atI.4't li{.1NS.
...www".wv" ".
GAUGE CFI:C .' ION DA'`" `. _ x 4 . MEC!I OR MITER RI,ADINjG _ ,
Y
.Sitfittl* ...yv r 11 .s4
F �__.. _. _� _�
Et CIT ASrU71)RESS d PPM
t76Sil'141'v 1111 J
/
''ll
_ SERVICE RESTORED
tt 9'0RT no ivw10: t131aR1:SI ti 111111 Or I3WNLR,
s4lilIIt tt':1'€'IRS1sr]',£min 11m, tISOU49III(OM 1'11LIIM ILSI£-:RCI)i`'i'