HomeMy WebLinkAboutPermit Backflow Test 2008-3-26
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PNWS-A WW A
aS3250
DNEW
I!!J EXISTING
BACKFLOW ASSEMBLY TEST REPORT 0 REMOVED
PROPERTY -:t4, Ch 0 REPLACEMENT
OWNER ~P~IN&F/f3.W Sc..HO<X D!!,T,( PHONE 7#.6375
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CITY ~fR.lrJ&FI.(L.() STATPORf~ ZIP 'i747'6
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STREET
DR P B A ~r D C V A 0 R P DAD D CD A 0 P V BAD S V BAD A V B 0 AIR GAP
SIZE 1~11,.,~,5l MAKE c.oNBv2A.LO MODEL 4"1 D b'l'i T
WATER SERIAL t\ A Q
PURVEYOR S. () \ e . NUMBER IV~ 3 '1 S" 0
ASSEMBLY.. 1
LOCATION WODDS HOP ~ I R 1't , Cr~ T' ON
REDUCED PRESSURE ASSEMBLY PVBA/SVBA INITIAL TEST
NI CHECK , DOUBLE CHECK' AIR CHECK PASSED mJ
PRESS DROP (A)I CHECK #1 INLET FAILED 0
INITIAL RELIEF VALVE (B)ITIGHT lBJ 2.0 OPENED AT PRESS DROP
TEST OPENED AT DATE
MIN 2 PSID !LEAKED 0 PSID '3/'2.6 10S
RESULTS BUFFER PSID PSID
A. B: I CHECK #2
MIN 3 PSI lIDa,~
RELIEF VALVE ITIGHT OlD NOT FAILED SYSTEM
PASS 0 FAIL 0 I LEAKED 0 PSID OPEN 0 0 PSI
COMMENTS
REPAIRS
AND/OR
PARTS
TEST
AITER
,REPAIRS
REDUCED PRESSURE ASSEMBLY
NICHECK , . ' ""CV'A
PRESS DROP (A) I.', ,- ./
RELIEF I CHECK #1
OPENED (B) TIGHT 0 PSID
....,PSlD i
BUFFER CHECK #2
A.B- I 0
.....PSI TIGHT PSID PSID PSID
IN COMPLETING AND SUBMrrTlNG TIllS TEST RIoPORT. TIlE TESTE :, CERTIFIES nlA T lliE
ASSEMBLY HAS BEEN TESTED AND MAINJ"AINED IN ACCORDANCE wrrn ALL APPLICABLE
RuLES AND REGULATIONS OF TIlE WATER SYSTEM. AND STATE REGULATIONS
GAUGE CALIBRATION DATE 11 111 /O!!bETECTOR METER READING
q~~ -Z? i4-vJ4f!.-. ~ &-- 4 4 (
~STER SI<lNAW/~ R.'I K . 8 . k/A. LOt'. 6-~t? he; CERH
TESTE~~t,Mt.~RJ~D PI L P I t\l E R OM) J (Y) J N R Of I aI., q74 S6 A4 ,,~u~ iG
TE2?~t~RNYr{ It: LO 0( HoOL.-' () 1t;'T I JI 1"1 PHONE N
COMPANY NAME
PVBA/SVBA
AFTER REPAIRS
DATE
OPENED AT PRESS DROP
/
PASSED 0
/
REPORT RECEIVED BY
(REPRESEIrrATIVE OF OWNER)
. OJ: SERVICE RESTORED
WHm ' Water System Copy
PINK, Customer Copy
YELLOW. Tester Copy