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i CNEW
PNWS a ❑EXISTING
e ='"'µ '_• BACKFLOW' SSEMBLY TEST REPORT ❑REMOVED
PROPERTY�r I � V tv J �� t /l PHONE: ❑REPLACEMENT
OWNER: t I I �/
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CITY S 1 ` 1 STATE(1 ZIP ` 'PI �1 '
ASSEMBLY I `` / I i/�
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❑IZE.e�.$L'MA E.P IA ❑ LkI I--I V ) ❑MODEL: i /�/v/r�( 7
PURVEYOR: S'� +Il�/IlJ\ NUMBER:
ER: � D-I I '\
LOCATION:ON: l-. } N , 1 { (') 19, ,e /1
- REDUCED PRESSURE ASSEMBLY 'J P.V.B.A / S.V.B.A INITIAL TEST
NI CHECK VDDUBLE.tHECK.' AIR CHECK PASSED 0
PRESS DROP (A)I CHECK NI INLET FAILED ❑
INITIAL RELIEF VALVE B ITIGIIT aLILL)OPENED AT PRESS DROP p
TEST OPENED AT MIN 2 PSID ( ) LEAKED❑ PSID -/ J-3 1 �1
RESULTS BUFFER I PSID PSID (s(1 ^
A-B= I CHECK #2 iTh
MIN E P51 (TI ®
FIGHT 6 DID NOT FAILED SYSTEM
RELIEF VALVE PsD OPEN ❑ ❑ PSI,
PASS ❑ FAIL' 1:1 1LEAKED❑
..i
•COMMENTS
REPAIRS
AND/OR. •
PARTS
• REDUCED PRESSURE ASSEMBLY - ` P.V.B.A./S.V.B.A. AFTER REPAIRS
NI CHECK (A)I DC,VA= DATE:
PRESS DROP
TEST -RELIEF (CHECK NI 1 ' OPENED AT PRESS-DROP
AFTER OPENED (8) TIGHT ❑Y PSID
REPAIRS 1°"•m (CHECK b2 •
_
A-B- rr9 ITIGHT ❑ PSID - PSID PSID PASSED ❑
IN COMPLETING AND SUBMTITING THIS TEST REPORT,THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WTTH ALL APPLICABLE
RULES AND REGULA S P-11.1ETER SYSTEM, AND STATE REGULATIONS.
i GAUGE CALIBRATION DATE —DETECTOR METER READING
TESTER SIGNATURE� lace CERTN
IESIiI� 5T$ Fiv
g_¢�$7 $PRINGFlELD 09051907 GAUGE R
TrrSTh R NPWEY FlRE PROTECTION 741-1775 PHONE.
COMPANY NAME
❑ SERVICE RESTORED
REPORT RECEIVED BY: (REPRESENTATIVE Of OWNER)
WHITE-Water Sys Copy • PINK-Customer Copy YELLOW-Tesler Copy