Report (2) its zot'003?1 1805326
BACKFLOW �
PREVENTER REPORT tt,, � j` EXISTING REMOVED REPAIRED REPLACED OLD S/N
PROPERTY NAME A)I I)0 Iv A ro K 1/.01- 11 PHONE
CONTACT NAME '19 ,r i E PHONE
MAILING ADDRESS I ) 4 NV S 5 tT AI OV y I d 1 p5� �y
CITY , I 1 14V(�, STATE Ola ZIP q 7 2 74
PREVENTER ADDRESS tt [� a (f
WATER SUPPLIER
o 19 U(r 61SERIALP H E A t /z c
LOCATION FI .k OF :'- Vi 44ua/ / i1 p 14$11-64' {'e 4
MAKE F Lot c, MODEL 650 SIZE 1 01
TYPE RP RPDA RPDA-II 4 DCDA DCDA-II PVB SVB AVB AG
HAZARD PROTECTED PREMISE ISOLATION FIRE SYSTEM BOILER OTHER
APPROVED: ASSEMBLY ORIENTATION AIRGAP PIPE SIZE in in
REDUCED PRESSURE ASSEMBLY PVBA/SVBA INITIALTEST
CHECK#1 DOUBLE CHECK AIR INLET CHECK VALVE
OPENED AT: PRESS DROP: •�JY
PRESS DROP: CHECK#1 TYPE II FAILED
MIN 5 PSID - yy
INITIAL RELIEF VALVE A. ErTPt '. 2 • M N F PS D M N e PSID DATE 'i G Q
TEST
RESULTS LEAKED MIN 1 PSID OPEN }F'}�
OPENED AT: SYSTEM PSI+V
MIN?PSID CHECK'#f2 FULLY FAILED
DETECTOR METER
RELIEF VALVE
2 S DID NOT READING:
PASSED FAILED OPEN
LEAKED MIN I PSID
NOTES 'X / A;ry
REPAIRS \.--. /- (V a W
PARTS
REDUCED PRESSURE ASSEMBLY PVBA/SVBA REST
AFTER REPAIRS
CHECK#1 DOUBLE CHECK AIR INLET CHECK VALVE
PRESS DROP:
CHECK#1 TYPE II OPENED AT: PRESS DROP:
MIN 5 PSID DATE
REPAIR RELIEF VALVE TIGHT - MIN I PSID MIN I PSID
RESULTS MIN I PSID PASSED
OPENED AT: CHECK#2 OPEN
MIN 2PSID FULLY FAILED
RELIEF VALVE _ TIGHT,
MINI PSID
PASSED� FAIILL�ED?
GAUGE SIN_DI 2 0 p'7 G q MAKE/MODEL e'4 S" 5 CALIBRATION DATE R I Z et Za
In completing and submitting this test report,the tester certifies that the assembly was tested and maintained in accordance with all applicable
rules,laws codes and regulations of the state and water system using approved testing equipment and approved testing procedures.
INTIAL TEST TEST AFTER REPAIRS
TESy� Ai TESTER SIGNATURE b It 3
it II •
rS TESTERS CERT#
TESTER 2[,1'M�E(PRRI ) i- TESTER NAME(PRINTED) .
1522.1 nv,cIe PHONE#
TESTER ADDRESSy / TESTER ADDRESS
ore-400 4OY Ct I fi. 4 7`'']01 S EMAIL
-
COMPANY rx ei.te'1NAME `i L }. NY NAME WATER RESTORED?
REPORT RECEIVVEEDBBYY`(RRE+ SE
PRRESENTATION OF OWNER) I/. REPORT RECEIVED BY(REPRESENTATION OF OWNER)
WHITE-UTILITY COPY • YELLOW-CUSTOMER COPY • PINK-TESTER COPY