HomeMy WebLinkAboutLawn Sprinklers NEWWA Backflow Prevention Device Assembly Test Report Form
Owner of Property 41 CJC r Date 7/l 8 ,
l /7 Time Y zo r^
Mailing Address -SS T^ d'1 / rd Tested by zAAo ro&e_S
tikA ca.S V, i It, 04r 3$d AT
Certificate# O . � 2S
o44
(City,Town) (Zip)
Contact Person �,v`'tL a J 41'0,4 C RPZ,' DCVA❑ PVB 0 SRVB 0
Make r-rtxt, Model No. l/
Device Address and Location ALAI I at LCk o P Size .2/411 Serial No. 70 y 9g
libt„st� Test After Installation 0
Device Identification Number Z d & ti1 f Test After Repairs P
Annual Test 0
Test Kit Serial# S gin"a Calibration Date /31 i I ki Other ❑
d.Pressure Baow Prevention Device Assembly(RPZJ Pressure Vacuum Breaker(PVB)
Reduce
' z: ' Spill Resistant Vacuum Breaker(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 Dp Evaluated
- - - - - - - - - - - - - - -•-•--------- -•
Evaluated-•-•-•---• Point--------•-----•---•---•-- - ---•-•-•---•-• •---•-----•-•---___---
Closed Tight JC Closed Tight ' Flow ❑ Opened at PSID Flow 0
Leaked 0 Leaked 0 d . a •D - . No-Flow 0
—
No-Flow PSID PSID •
41 . Did Not Open 0
PSID
* , t z t Double Valve Device l *m • Air Inlet Valve PP Opening Point
Backpressure Test Check Valve No.l Check Valve No.2 Flow Condition
DP DP Evaluated
TC#1 PSI TC#4 PSI PSID
Flow❑ -
PSID PSID v
No-Flow 0 Did Not Open 0
1'
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 Line 0 Fire Service Line 0 Internal Domestic Plumbing System 0
Signature of Certified Tester PASS P FAIL 0 OTHER 0
Test Witnessed by. Remarks
Water Works Official
)caner Agent
State Official Service Restored 0