2990 Lexington Ave - RPZ ReportsANNUAL TEST FORM
BACKFLOW PREVENTORS
CUSTOMER:
STREET ADDRESS:
MAILING ADDRESS:
NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY S.N.:
LOCATION OF ASSEMBLY:
TYPE OF ASSEMBLY: RPZ DCV PVB SVB SIZE: INSTALLATION DATE:
MANUFACTURER: MODEL: SERIAL #:
RELIEF VALVE CHECK VALVE #2
Back Pressure
Test
CHECK VALVE #1
In Direction of
Flow Test
CHECK VALVE #2
In Direction of
Flow Test
Pressure/Spill
Resistant
Vacuum Breaker
DOUBLE CHECK VALVE
In Direction of Flow Test
Opened at
________ psid
Did Not
Open
Leaked
Closed Tight
Leaked
Closed Tight
Differential Pressure
Across check valve
________ psid
Leaked
Closed Tight
Differential Pressure
Across check valve
________ psid
Air inlet opened at
________ psid
Did Not Open
Check Valve
Leaked held at
________psid
#1
Leaked
Closed Tight
________ psid
#2
Leaked
Closed Tight
________ psid
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
CHECK ALL THAT APPLY
Cleaned Only Cleaned Only Cleaned Only Cleaned Only Cleaned Only
#1
Cleaned Only
#2
Cleaned Only
Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Replaced:
Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit
Assembly Assembly Assembly Assembly Assembly Assembly Assembly
Disc Disc Disc Disc Disc, air in Disc Disc
Diaphragm Spring Spring Spring Disc, CV Spring Spring
Spring O-rings O-rings O-rings Spring, air O-rings O-rings
O-rings Other Other Other O-ring Other Other
Other Other
Describe Repairs:
Opened at
________ psid Closed Tight
Differential Pressure
Across check valve
________ psid
Differential Pressure
Across check valve
________ psid
Air Inlet_________ psid
Check valve ______psid
Check #1 ________ psid
Check #2 ________ psid
Opened shut off #1 Opened shut off #2 Water Pressure: Test Kit SN:
Remarks:
I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly.
TESTER’S NAME (print) CERT. #
TESTER’S SIGNATURE DATE TIME
COMPANY
Davis Mechanical Systems Inc.
21225 Hamburg Ave Suite 3
Lakeville MN 55044
952-854-3654
ANNUAL TEST FORM
BACKFLOW PREVENTORS
CUSTOMER:
STREET ADDRESS:
MAILING ADDRESS:
NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY S.N.:
LOCATION OF ASSEMBLY:
TYPE OF ASSEMBLY: RPZ DCV PVB SVB SIZE: INSTALLATION DATE:
MANUFACTURER: MODEL: SERIAL #:
RELIEF VALVE CHECK VALVE #2
Back Pressure
Test
CHECK VALVE #1
In Direction of
Flow Test
CHECK VALVE #2
In Direction of
Flow Test
Pressure/Spill
Resistant
Vacuum Breaker
DOUBLE CHECK VALVE
In Direction of Flow Test
Opened at
________ psid
Did Not
Open
Leaked
Closed Tight
Leaked
Closed Tight
Differential Pressure
Across check valve
________ psid
Leaked
Closed Tight
Differential Pressure
Across check valve
________ psid
Air inlet opened at
________ psid
Did Not Open
Check Valve
Leaked held at
________psid
#1
Leaked
Closed Tight
________ psid
#2
Leaked
Closed Tight
________ psid
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
CHECK ALL THAT APPLY
Cleaned Only Cleaned Only Cleaned Only Cleaned Only Cleaned Only
#1
Cleaned Only
#2
Cleaned Only
Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Replaced:
Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit
Assembly Assembly Assembly Assembly Assembly Assembly Assembly
Disc Disc Disc Disc Disc, air in Disc Disc
Diaphragm Spring Spring Spring Disc, CV Spring Spring
Spring O-rings O-rings O-rings Spring, air O-rings O-rings
O-rings Other Other Other O-ring Other Other
Other Other
Describe Repairs:
Opened at
________ psid Closed Tight
Differential Pressure
Across check valve
________ psid
Differential Pressure
Across check valve
________ psid
Air Inlet_________ psid
Check valve ______psid
Check #1 ________ psid
Check #2 ________ psid
Opened shut off #1 Opened shut off #2 Water Pressure: Test Kit SN:
Remarks:
I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly.
TESTER’S NAME (print) CERT. #
TESTER’S SIGNATURE DATE TIME
COMPANY
Davis Mechanical Systems Inc.
21225 Hamburg Ave Suite 3
Lakeville MN 55044
952-854-3654