Laserfiche WebLink
BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />NAAIE OF PREAIISE.' Ankle- <br />F-i-NC t C ; n; <br />L C F EJ 'e C C1t <br />Commercial X <br />Residential L_ <br />SER VICE ADDRESS: 3131 <br />/JF95at 5t. <br />C/T)'.15J9-felt <br />ZlP: U.201 <br />CONTACT PERSO,Y: <br />LOCA TION OF ASSEMBLY. Lack izoQtex <br />PHONE: ( <br />FAX: ( <br />DOWNSTREAM PROCESS-' i,-Kay -DCVA: ❑ RPBA: X PVBA: ❑ OTHER: <br />NEB'INSTALL: S EXISTING: ❑ REPLACEAIENT. ❑ OLD SER. # PROPER INSTALLATION? YES 5Z NO ❑ <br />AfAKE OFASSEAIBL )': kLQ t S AIODEL: O(19 QT SERL4L ,'%'O.: ;2 9 4 ,� 9'i —SIZE: 1/a <br />n <br />DCI:4 / <br />RPBA <br />DCI A / <br />RPBA <br />RPRA <br />PI'BA / SVBA <br />INITIAL <br />CHECK I'ALVF. <br />N'O. ; <br />AIR INLET I ALVE <br />CHECK IS1L1'EN'O. 1 <br />TEST <br />OPE:1'F_D.4T'38 PSID <br />CLOSED TIGHT R <br />CLOSED TIGHT <br />OPENED AT <br />PSID <br />❑ <br />#I CHECK 7. P PSID <br />LEAKED <br />r' <br />LEAKED <br />❑ <br />PASSED J3 <br />41R GAP OK? N-S <br />DID NOT OPEN' <br />4• y <br />PSID <br />FAILED ❑ <br />PSID---- <br />CrrAN RMACF. <br />rwr <br />Ct.Eas RErverE <br />PART <br />CLEO R::PEACF. rART <br />CHECK I ALI'E <br />N'EII' <br />0 D <br />11 <br />❑ ❑ <br />HELD AT <br />PSID <br />PARTS <br />❑ <br />- ❑ <br />❑ ❑ <br />LEAKED <br />`l <br />AND <br />❑ <br />REPAIRS <br />0 <br />_ 0 <br />0 0 <br />CLEANED <br />REPAIRED <br />❑ <br />TEST AFTER <br />REPARS <br />LEAKED <br />LEAKED <br />❑ <br />OPENED AT_PSID <br />:IIRINLET <br />PSID <br />PISSED 2 <br />PSID <br />PSID <br />#1 CHECK_ PSID <br />CHK MALVE <br />PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum airgap separation provided? )'Cs: ❑ No: 0 Detector Meter Reading: <br />REMARKS: Na55a!A NQAiCZl LINE PRESSURE:—qO PSI <br />P,.C-r Gt ed F—rlu6 Ptee--zQl CONFINED SPACE? �o <br />TESTERS SIGNATURE: &Zl-� (J Q-r--CERT. NO.: [14643 DATE: <br />TESTERS NAME PRINTED: I,n:V TESTERS PIION'E:(-==)1;'9-11:K TESTERS EMAIL: BCB.ick(la%as:c.ntsn.com <br />REPAIRED BY: <br />FINAL TEST BY: <br />CERT. NO.: <br />VIA <br />Tr:: <br />CALIBRATION DATE. 09127 105 GAUGE. Mid \Pest Instruments MODEL: 830 SERI'ICE RESTORED? )'ES: A NO: <br />I earrih, lmi this report Is accamie, and 1 have used it AC246.190-I90 approved trsi mriltnds and test equipment. <br />.. ..___ i____.-r.r..T__.o_...._.........L�F.L,d..•irlrl.,�.,llt'..rorT)is,ri,-rht�(honnrnfrn�tttise'�JI <br />