HomeMy WebLinkAbout2018-07-20 Backflow Test Report o k, `Thr-L 5 c i)din !r pe 1,6)-(-k39—as-74
BACKFLOW DEVICE TEST REPORT
Service Address f LI iC b ( pe( &-kh 6+ AS r 1 z
Name of Premises bhr\ �O VQn iati Location of device t ?7/ /7 -5r
Device Wr /1 r 720A rr �.�,C��'�
Model 54f at LS.
Test Kit
MNwf.#ue, Serial Numbtr -.D81O 06/55
RP
DC
DCDA❑ •
RPDA D
Reduced Pressure Principle AsseinbI
Relief Valve Check Valve#2 Check Valve 114 No.2 Sh1 toff Check Valve#2
Opening Point Backpressure Test Valve;
Opened at paid Closed Tight 0 Held at psid '` leced Tight 0 Held at paid
Leaked 0 Leaked
Did not open 0 Leaked.; 0 Leaked 0
d
Double Check Valve Assenxbly' Backflow
Assembly Status
Check Valve#2 Check Valve#1 No.2:Shutoff Check Valve#2
Backpressure Test Valve Passed
Closed Tight 0 Held at paid ' Closed Tight ❑ Held at paid Failed 0
Leaked ❑ Leaked ❑
Leaked 0 Leaked 0
Date 7-2O -/g• { ire st oc>n Certified Tester#(32.C65- UG 137710
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Test by(Signature) Print Name 3L'€2-F J JJe L 3
Your signature certifies that all informati provided on this section is correct.
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