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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />ACCOUNT# <br />NAME OF PREMISE <br />Commercial, I Residential ❑ <br />SERVICE ADDRESS 19 L 0 1j,) -af' 11'1 1 \JQ, CITY y-{' ZIP q� <br />CONTACT PERSON( IV. �m mil '�� PHONE (3&0) 305 _ taUl 3 FAX ( ) <br />LOCATION OF ASSEMBLY WE C of- r- j r ke n 1- h , ncl A i 5k k r- <br />DOWNSTREAM PROCESS�I�' `J1 L.)c'� S C- <br />NEW INSTALL EXISTING ❑ REPLACEMENT ❑ OLD SER. # <br />DCVA ❑ RPBA)R; PVBA ❑ OTHER <br />PROPER INSTALLATION? YESONO ❑ <br />MAKE OF ASSEMBLY �,)A MODEILF609 CST SERIAL NO. f (S0 ;!. SIZE Il a q <br />DCVA / RPBA <br />DCVA / RPBA <br />RPBA <br />PVBA/SVBA <br />INITIAL <br />CHECK VALVE NO.1 <br />CHECK VALVE NO.2 <br />AIR INLET <br />TEST <br />OPENED ATj• � PSI <br />CLOSED TIGHT' <br />OPENED AT PSID <br />LEAKED ❑ <br />LEAKED ❑ <br />#1 CHECK • Q PSID <br />PASSED] <br />DID NOT OPEN ❑ <br />FAILED ❑ <br />LA ' _ PSID <br />PSID <br />AIR GAP OK? U <br />CLE.,N REPL-kCE PART <br />CLEAN REPLACE PART <br />CLEAN RFPLACF PART <br />CHECK VALVE <br />NEW <br />❑ ❑ <br />D ❑ <br />❑ ❑ <br />HELD AT PSID <br />PARTS <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />LEAKED ❑ <br />AND <br />REPAIRS <br />❑ El <br />❑ <br />❑ ❑ <br />CLEANED ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />-- — <br />REPAIRED ❑ <br />TEST AFTER <br />CLOSED TIGHT <br />REPAIRS <br />LEAKED ❑ <br />LEAKED ❑ <br />OPENED AT PSID <br />AIR INLET PSID <br />PASSED ❑ <br />PSID <br />PSID <br />#1 CHECK PSID <br />CHK VALVE PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum air gap separation provided? Yesx No ❑ Detector Meter Reading <br />REMARKS: <br />TESTERS SIGNATURE:`� <br />TESTERS NAME PRINTED: Rack I If10Ch10 <br />REPAIRED BY: <br />FINAL TEST BY: <br />LINE PRESSiA2Et)5` �P�SI <br />t-� CONFINED SPACE? <br />CERT. NO 1 I DATE 5 <br />TESTERS PHONE z ( <br />CERT. NO. <br />DATE <br />DATE <br />LIBRATION DATE 71 Q(P-/a_aGAUGE #tfb MODELBj-fS- 5SERVICE RESTORED? YESIR NO ❑ <br />IIQU^Il8 <br />I certify that this report is accurate, and I have used 'RAC 246-290490 approved test methods and test equipment. <br />