HomeMy WebLinkAboutSprinkler Backflow Test Report 2017 NEWWA Backflow Prevention Device Assembly Test Report Form
Owner of Property at Date 2 p f; _V z-7//7 Time ' 30
( Mailing Address � _ 0- t r brV,�h PW�-k Tested by I o J�' )— t1 A ' \U (LP)
Contact Person RPZ I- DCVA❑ PVB 0 SRVB 0
Make PC.o Model No. 8 2.5 Y
Device Address and Lgcation klVt C Size 3A-1 Serial No. To 7 8 I Z. l
t1 ACk,f_r- b CN,,C,kr Ci'r(`-c Test After Installation 0
Device Identification Number ' O d i Z.l Test After Repairs 0
Annual Test C
Test Kit Serial# l6 -Lig()f 1 Calibration Date LD/a 3/) d Other 0
•
• .�-.. _ - _ . �'-" r. Pressure Vacuum Breaker(PVB).
Spill Ra�sirt Vacnrier:Breka(SRVB)
Check Valve Check Valve Flow Relief Valve Check Valve .Check Valve Flow Condition:
No.1 No.2 Tightness Condition DP Opening No.2 DP Evaluated.
Evaluated Point DF ,
Closed Tight 1! Closed Tight Opened at PSID .. . Flow ti
Flow El
g ( _ ' T .
Leaked 0 Leaked 0 2. ,
;;;fes,` :. ' : i�o-Flgt ia:``
Q No-Flow 0 PSID rtpxtma'orv„.. .li;iit.it. ...:.!:::::::::::-...� ►O • b DId Not OpeLl❑ ` #�' : ;;q•. '
PSID • •0Y .0,':`,:e }i ' 4.'4;"� r"' .-:,.v Y^"' '.
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_ ! �.TSD ^".'s..."t''...1!'.',:: :,'Kr.
e. Backpressure Test Check Valve No.1 Check Valve No.2 Flow Condition •:} .r AIM:: , �s� ;t.
DP DP Evaluated i , ': ..
TC#1 PSI TC#4 PSI ----•-----•-------•--------------•--------- ,
V 4 t IDt yii
Flow❑ •
6 •;:, ., , • W
PSID PSID 1Tyi,Rft>.4 Ds . a
j
No-Flow 0 t'.-; , 6 '4,:ii
At the time of the test,the downstream shut-off valve was: Closed Tight 0 Leaked 0 Not Tested 0
Line Pressure PSI Protection Type:Service T it+n 0 Fire Service Line 0 Internal Domestic Plumbing System 0
-114.4(0...... PASS Il FAIL 0 OTHER ❑
Signature of Certified Tester
Test witnessed by: Rema
Water works official
�•
-*net Agent
State official Service Restored .❑