4-18 667 Lexie CourtBACKFLOW PREVENTER TEST REPORT
#,STREET
rsoJcwros.T lnrVttmAIIVN(All Fields are Required)
System Served. —ILL' ,ti Manufacturer of Assembly: Model
Size of
t� ` Serial #, A:' Qt vs 4U
Location of Assembly: Floor # C'itr.�Y'CfCYlcS Room It
Date test was performed: 'o'a
Reduced Pressure
Principle Backflow Prev ter (RP) —TEST RESULTS
Check Valve #2
Shutoff Valve #2 Check Valve #1
Pressure Differential
Relief Valve
Initial Test
Closed Tight Yes -No
—
Closed Ti ht Yes No Closed Tight _Yes_No
g
— — Pressure Drop Across
Opened at psid
Check Valve #1 psid
Describe parts and
repairs when needed
Final Test
Closed Tight,Z Yes No Closed Tight Yes Closed Tight Yes_No
—
—No
Pressure Drop Across
Opened at �2 psid
Check Valve#1 o psid
Double Check Backflow Prevention Assembly (DC) — TEST RESULTS
Check Valve#1
Check Valve#2
Shutoff Valve#2
Closed Tight —Yes No
Closed Tight No
Initial Test
—Yes —
Closed Tight _Yes No
psid
Sid
Describe parts and
repairs when needed
Closed Tight —Yes No
Closed Tight
Final Test
—Yes —No
Closed Tight —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
Initial Test
_Yes_No
Pressure Drop Across
Closed Tight Yes No
g — —
Opened at psid
Check Valve #1 psid
Describe parts and
repairs when needed
Closed Tight
Final Test
Opened at psid
—Yes—No
Pressure Drop Across
Closed Tight Yes No
— —
Check Valve #1 psid
CERTIFICATION: I c ify the foregoing information provided by me to be Ccome n t t tested device is functloning with the limits of the standards.
Name (Print) Signature; �t c('} ^ Signature; Q. Dater,/
State of MN Certificate Number: � 1 C ty l I9 O'