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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