HomeMy WebLinkAbout2017-08-10 Backflow Test Report at E, Th i-95 d,''1dih 1 d- t:6)-03q-(as-(/
BACKFLOW DEVICE TEST REPORT
Service Address Iy IKi b pr
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Name of Premises UCS)f WrqD t5ZO'1 Location of device 74.",-.,,,‘t of 16 k S .
Device cOrIkjn (V6 ler 30--CO
M al alai Site Serial Number
Test Klt
MmcFaa2cr Serfs!Numbe Daze Camel
RP 0
DC
DCDA❑ '
RPDA D
Reduced Pressure Principle Assetnblj
Relief Valve Check Valve#2 Check Valve#1 No.2 Shutoff Check Valve#2
Opening Point Backpressure Test •Valve,
-
Opened at paid Closed Tight 0 Held at 2, paid ?4ed Tight 0 Held at paid
Leaked 0 • Leaked- 0
Did not open 0 I Leaked, ❑ Leaked 0
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Double Check Valve Assembly. Backflow
` Assembly Status
Check Valve#2 Check Valve#1 No,a'Shutoffl"" I Check Valve#2
Backpressure Test Valve Passed X(
Closed Tight ❑ Held at paid - Closed Tight ❑ Held at psld Failed ❑
Leaked ❑ Leaked 0
Leaked 0 Leaked 0
Date C-10—I7 .s Tillie 1:. 6 Certified Tester#(-37/A6--� — C!G 57-7/057-7/085,'7/L7
Test by(Signature) j�/\ / c J!'F'+Print Name 1 Iver��
Your signature certifies that ail information provided on this section is correct.
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