1950 Rahncliff Ct - RPZ Test ReportBACKFLOW PREVENTER TEST REPORT
2-'a-
BACKFLOW ASSEMBLY INFORMATION (All Fields are Required)
System Served:Pr i C�r�� Manufacturer of Assemblyt n�I 1--12 Mojdel>��"t3 ems[ t
Size of Assembly J``/4t Serial# L / 79�LP -'1(�
Location of Assembly: Floor # "POA `NOi�A Room # Date test was performed: ' O�q \
Reduced Pressure Principle Backflow Preventer (RP) —TEST RESULTS
Check Valve #2
Shutoff Valve #2
Check Valve #1
Pressure Differential
Relief Valve
Initial Test
Closed Tight x>/es—No
Closed Tight Yes _No
—
Closed Tight—Yes_No
Pressure Drop Across
Opened at psid
Check Valve #1
Describe parts and
.psid
repairs when needed
Final Test
Closed Tight/>OYes No
Closed Tight Yes —No
Closed Tight/O Yes_No�/
Pressure Drop Across
Opened at ^ sid
Check Valve #1 4 a psid
Double Check Backflow Prevention Assembly (DC) —TEST RESULTS
Check Valve 91
Check Valve #2
Shutoff Valve #2
Initial Test
Closed Tight _Yes _No
Closed Tight _ Yes _No
Closed Tight —Yes—No
psid
Psid
Describe parts and
repairs when needed
Final Test
Closed Tight —Yes—No
Closed Tight _ Yes _No
ClosedTight _Yes _No
psid
psid
Pressure Vacuum Breaker Assembly (PVB)
or Spill Resistant Vacuum Breaker
(SRVB) —TEST RESULTS
Air Inlet Valve
Check Valve
Shutoff #2
Failed to Open_ Yes No
Closed Tight Yes
Initial Test
_ _No
Pressure Drop Across
Closed Tight _Yes No
Opened at psid
Check Valve #1 psid
Describe parts and
repairs when needed
Closed Tight Yes
Final Test
Opened at psid
_ _No
Pressure Drop Across
Closed Tight —Yes—No
Check Valve #1 psid
CERTIFICATION: I c rt#y the foregoing information provided by me to be corre nd t the tested device Is functioning with the limits of the standards.
Name (Print). �"'��yy �+l "�Signature: Date:
State of MN Certificate Number: s�i('L//''LD 1C�q C=)-