The URL can be used to link to this page

Home My WebLink About2022-09-30 Backflow Preventor (RPZ) Test Reports - NAC Mechanical BACKFLOW PREVENTER TEST REPORT JOB ADDRESS (INCLUDE ADDRESS #, STREET NAME, & DIRECTIONAL), Apt/Unit # BACKFLOW ASSEMBLY INFORMATION (All Fields are Required) System Served:_______________________________ Manufacturer of Assembly:___________________ Model #________________________ Size of Assembly:________________________________________ Serial #_______________________________ Location of Assembly: Floor #__________________________________________ Room #______________ Date test was performed:___________ Reduced Pressure Principle Backflow Preventer (RP) – TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight ___ Yes ___No Closed Tight ___ Yes ___No Closed Tight ___ Yes ___No Pressure Drop Across Check Valve #1________psid Opened at ________psid Describe parts and repairs when needed Final Test Closed Tight ___ Yes ___No Closed Tight ___ Yes ___No Closed Tight ___ Yes ___No Pressure Drop Across Check Valve #1________psid Opened at ________psid Double Check Backflow Prevention Assembly (DC) – TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight ___ Yes ___No psid________ Closed Tight ___ Yes ___No psid________ Closed Tight ___ Yes ___No Describe parts and repairs when needed Final Test Closed Tight ___ Yes ___No psid________ Closed Tight ___ Yes ___No psid________ Closed Tight ___ Yes ___No Pressure Vacuum Breaker Assembly (PVB) or Spill Resistant Vacuum Breaker (SRVB) – TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open___ Yes ___No Opened at ________ psid Closed Tight ___ Yes ___No Pressure Drop Across Check Valve #1________psid Closed Tight ___ Yes ___No Describe parts and repairs when needed Final Test Opened at ________ psid Closed Tight ___ Yes ___No Pressure Drop Across Check Valve #1________psid Closed Tight ___ Yes ___No CERTIFICATION: I certify the foregoing information provided by me to be correct and that the tested device is functioning with the limits of the standards. Name (Print):_________________________________________ Signature: _____________________________________ Date: _______________ State of MN Certificate Number: ___________________________________