HomeMy WebLinkAbout2025-12-12 Annual Test - Backflow Preventers Report ANNUAL TEST— BACKFLOW PREVENTERS
CUSTOMER W ka,1
STREET ADDRESS CO 10 NUIZt�LC-A-i)&/V (Ai nfriz Mier ti , � S ?Z
• MAILING ADDRESS
PROPERTY OWNER
STREET ADDRESS
MAILING ADDRESS - . . ..
LOCATION OF ASSEMBLY NO/ {0001-1
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TYPE OF ASSEMBLY: RPZ ❑ DCV 0, PVB .❑ SIZE: 6
MANUFACTURER: ,AfirS MODEL: SERIAL It: NO/ 932
CHECK VALVE#2 CHECK VALVE#2 PRESSURE
RELIEF VALVE TEST#1 CHECK VALVE#1 • TEST*2 VACUUM
BACKPRESSURE CONFIRMATION BREAKER
❑ leaked ❑ leaked ❑ leaked air inlet opened at
Psi
opened ❑ dosed tight gi dosed tight Zi dosed tight did not open ❑
did not••-n ❑ Differential pressure Differential prey check .ve:
a s valve acre s check�a leaked ❑
pd �-9 /"" held at psi
❑ c•. •• •Ny ❑ C•. -•o El Cleaned only
❑ C only r • ❑ '•. -•only
Replaced: Repla•••': • Replaced: Replaced: Repla.••:
rubber kit ❑ rubber it ❑ rubber kit ❑ rubber • ❑ rubbe kit ❑
RV a ' ❑ CV. :I • ❑ CV assembly CV mblyA CV a ••mbly /.
or or • or or
disc ❑ disc ❑ disc ❑ disc ❑ disc,air II
di gm(s) o 1 ?s ❑ o-iings ❑ o-ri s ❑ disc,CV ❑
�\ [] , seat ❑ t ❑ spring -'r ❑
rig ❑ .'ng ❑ spring ❑ pang ❑ sot,CV ■_
g 'de. ❑ •tem/guide . ❑ \ stem/guide ❑ stem/guide ❑ •r \\
-rings ❑ retainer ❑ retainer ❑ retainer ❑ guide ❑
-other ❑ lock nuts ❑ lock nuts .❑ lock nuts ❑ o-ring U
other ❑ other ❑ other ❑ other ❑
Opened at • ❑ leaked Differential pressure Differential pressure Air inlet• psi
! .. across check valve across check valve Check
❑ dosed tight. Psi Psi valve Psi
-- ‘1111.1.0111111111111111.6
NOTE: ALL REPAIRS SHALL BE COMPLETED WITHIN TEN(10)DAYS.
REMARKS:
I HEREBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND
MAINTENANCE OF THE ASSEMBLY. .
TESTER'S NAME(PRINT) DeivAd. ileisw CERT_# -3376
TESTER'S SIGNATURE 1 U A•- DATE I_2/I.2(2C— �_
ANNUAL TEST— BACKFLOW PREVENTERS
CUSTOMER kliAL/Mr(
STREET ADDRESS k e DVO62l -L A'ti a 4/ chic 17l(cR6//. �.S,1i1 s3V8Z-
MAIUNG ADDRESS
PROPERTY OWNER
STREET ADDRESS
MAILING ADDRESS - . . ._
LOCATION OF ASSEMBLY (DEL.I
TYPE OF ASSEMBLY: RPZ ❑ DCV ❑ PVB ,1 SIZE: 3/4
MANUFACTURER: IidA'1Es MODEL: ..661 fr1 y SERIAL#: ®44 3 20
CHECK VALVE#2 CHECK VALVE#2 PRESSURE
SEISEPIMEVE/ TEST#1 CHECK VALVE#1 • TEST#42 VACUUM
,P Wv r.�1 ACKPRESSURE CONFIRMATION BREAKER
n leaked U leaked ■ leaked air inlet opened at psi
open at: i St •d not open ❑
a ,.osed tight dosed tight dosed tight pe
did not open ❑ ❑ Differential pressure rtferential pressure ' :•'' valve: 0
acrossc dt a a,•••ss check valy: ••
�L ,- hel. . Psi
❑ Cleaned only . ❑ C:. •• • ❑ Cleaned only ❑ •• ••or ❑ Cleaned only
Replaced: Replay-,: • Replaced: Replay- Repla,•••:
rubber kit ❑ rubber it ❑ rubber kit gr rubber ' ❑ ru •:r kit Li
RV assembly❑ CV. :! bly❑ CV assembly❑ CV a :',bly❑ CV a • • ❑
disc ❑ disc Cl disc , ❑ disc ❑ disc, 1, ❑
diaphragms) ❑ • o-ring. ❑ o-rings ❑ o-ri •s ■ disc, V ❑
seat ❑ seat ❑ . seat ❑ ►\ spri •,air ■
Ong ❑ "•• • ❑ spring ❑ s. 'ng a ,. ng,CV \\..__
guide CIs 'm/guide . CIstem/guide ❑ s em/guide ❑ retainer ■ `
o-rings ❑ •tamer ►\ retainer ❑ retainer ❑ guide ❑
other ' ❑ • lock nuts IM lock nuts .❑ lock nuts ❑ o-ring ❑
other ❑ 1 other ❑ other ❑ other ' ❑
Opened at ' ❑ leaked Differentiafpressure Differential pressure Air inlet• psi
Pc across check valve across check valve Check
❑ dosed tight- Psi Psi valve psi
NOTE: ALL REPAIRS SHALL BE COMPLETED WITHIN TEN(10)DAYS.
REMARKS:
I HEREBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND
MAINTENANCE OF THE ASSEMBLY.
TESTER'S NAME (PRINT) DM" 1��( CERT.# 33(.70
TESTER'S SIGNATURE ./�6 .(-1.7() _ DATE 12/1 Z' Z-S ,