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BACKFLOW ASSEMBLY TEST REPORT
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ASSEMBLY C'"': ~,.,
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9l\R.P.B.A. 0 6~Q.A. 0 R.P.p.A" gD.C.DA OP.V.BA OS.V.B.A. 0 A.V.B. o AIR GAP
SIZE: u..J. MAKE: tA...Ja-l-fs MODEL: OOq 6)T
WATER 5u,,(] SERIAL AC , j!2
PURVEYOR: J? NUMBER: ~) ~ .-)
ASSEMBLY I dr.' K
LOCATION: j n U.:JI n
DNEW
o EXISTING
o REMOVED
o REPLACEMENT
STAT"
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ZIP Cnl/7l
REDUCED PRESSURE ASSEMBLY I P.V.BA I S.V.BA
'I CHECK q 0 ' DOUBLE CHECK, AIR CHECK
PRESS DROP , (A'I CHECK #1 INLET
INITIAL RELIEF VALVE L/ J (B)ITIGHT 0 IOPENED AT: PRESS DROP
TEST OPENED AT , _
Mr;N PS/U ILEAKED 0 PSID
RESULTS BUFFER q
A _ B ,. J I CHECK #2 PSID PSID
MIN3PSI
ITIGHT 0_ DID NOT FAILED
o ILEAKEDO "'0 OPEN 0 0
INITIAL TJ>ST
PASSED .fl
FAILED 0
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RELIEF '0L VE
PASS 11 FAIL
.
SYSTEM
PSI
COMMENTS
REPAIRS
AND I OR
PAR.,.
TEST
AFTER
REPAIRS
~
"CHE~iDUCEDPRESSURE ASSEMBLY P.V.B.A.lS.V.B.~--=; ~REPAIRS
PRESS DROP (All DCVA . !DA~
REUEP I CHECK #1 _ OPENED AT PRESS DROP f
OPENED (B) TIGHT 0 PSlD I I
_1- i
"i":':~ jCHECK #2 - PASSED 0
_... TIGHT 0 PSID PSID PSID
IN COMPLETING AND SUBMrI11NG nlls TEST REPO.:T, llIE TESTE.: Cc......r.r... .nAT TIff
. . ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE wrrn ALL APPLICABLE
RULES AND REGULATIONS OF T1iE WATER SYSTEM. AND STATE REGULATIONS.
GAUGE CALlBRAT N DATE......l-..,.... DETECTOR METER READING
C) lJ. (~
TESTER SIGNAl\JRE ~.
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TESTER' NAME P1UW'157 S. 47TH GT. SPRlNGRBD
TESTERSADDRES' OMUD & SWINNEY fIRJ: PRUII:G lION
REPORT RfCEIVED BY:
(REPRESENTATIVE OF OWNER)
4315
. 03?Jl0
74YniD. PHONE'
PSERVICE RESTORED
CERT'
GAUGE .
COMPANY NAME
WHITE,. '!I*' System Copy
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YELLOW. TCIla Copy