1008 Diffley Rd - RPZ ReportJOB ADDRESS
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BACKFLOW PREVENTER TEST REPORT
DE ADDRESS p, STREET NAME, & DIRECTIONAL), Apt/Unit P
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BACKFLOW ASSEMBLY INFORMATION (All Fields are Required)
r, C wan Manufacturer of Assembly: il K:rt5 Model 7�0 _A
System Served: �fi�
Size of Assembly: Serialp
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R;j CLOdn Roomp
Date test was performed:.r f+i -z
Location of Assembly: Floor
Initial Test
Describe parts and
repairs when needed
Final Test
Initial Test
oescribrts and
repairs when needed
FinalTest
Initlal Test
Reduced Pressure Principle Backflow Preventer tKVJ
Shutoff Valve pi Check Valve Ml
Check Valve n2
Dosed Tight _Yes_
8 Yes_No Pressure Drop Across
Closed Tight _Yes_No ClosedTilit _ I„A• et
UVacu ..e...
Closed Tight _ye5—
No Closed Tight _ yes —No Pressure Drop Across
Check Valve ply
Double ChecR uauisn. 1.
Check Valve Nl No Clr
ased Tight
psid
Ck
osed Tight Yes —No
Sid
Lim Breaker Assembly (PVB) or SPIII
Air Inlet Valve closed
to openYes No Pressure
Check Vt
1 . 9 osid
Yes �No
pescri;;p sand Closed Ti_
ght Across
when needed pressure Drop Sid
repairs psid deck Valve al deviceis
Opened at a to be correct and that the tested
Final Test rovided by n'
information p
foregoing gignamre:
CERTIFICATION' I certify the 0�
(Print
Name):
Number:
State of MN Certificate
pressure
opened at psid
Opened at _psid
Closed Tight _Yes —No
closed Tight —
Yet _No
ves NO
Closed Tight
d Tight
Yes No
Close
the of the standards
Date: -. l � ����