Loading...
3035 Holiday Lane - RPZ Report 5/24/2413ACKFLOW PREVENTER TEST REPORT "ir,� S-513 Manufacturer of Assembly: tt li& .q Model# C-u XL Sure of Assembly: 3/L Vl p Serial lt�� �� 1� Location of Assembly: Floor# k^si\. n G^ { Roomd Date test was performed:J[y`7") Reduced:P,ressureRrlOdple RP) —TEST RESULTS Check Valve#2 Shutoff Valve 92 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight _Yes —No Dosed Tight —Yes Closed light —Yes—No —No Pressure Drop Across Opened at psid [heck Valve pl sid Describe parts and repairs when needed Flnal Ten Closed Tight �Yes_No Closed Tight >*Yes Closed Tight, Yes —No —No Pressure Drop Across Opened at.-_psid Check Valve#1 4.1 psid Double Check BReknow Prevention Assembly (DC) -TEST RESULTS Check Valve#1 Geck Valve#2 Shutoff Valve#2 Closed Tight—Yes_No Closed light Initial Test —Yes_No Closed Tight —Yes d sid _No Describe parts and repairs when needed Closed Tght _Yes —No Closed Tight final Test -Yes—No Closed fight —Yes—No psid psid ` Pressure Vacuum Breaker Assembly fPVB) or Spill Resistant Vacuum Breaker (SRVB) -:TEST RESULTS Air Inlet Valve Check Valve Shutoff#2 Failed to Open —Yes —No Closed Tight —Yes—No Initial Test Pressure Drop Across Closed Tight —Yes—No 0 ened at sid Check Valve 91 sid Describe parts and repairs when needed ClosedTight Final TTestOpenedat__psld —Yes—No Pressure Drop Across ClosedTight —Yes —No CheckValvi psid ........—••-^ .1=•vWa mrosmatgn provided by me to be co e[ + a`he tested device is tuncuoning with the limits of the standards. Name (Print), �`i(\ rZQPky D,� Slgnrture Date: a� State of MN Cerfificate Number: BACKFLOW PREVENTER TEST REPORT BACKFLOW Abbtill i IrvraanlrrrT16 f e Model k System Served: c"�l �C�'+� Manufacturer of Assembh/:S- �� . . SerialN r I/A size of Assembly: Room 3i ,� Room d Ny*�^' n-r�^" Date test was performed: Location of Assembly: Floor e,Q Initial Test Describe parts and repairs when needed Final Test initial Test Describe parts and repairs when needed Final Test Initial Test Check Valve#z � �•�^""" Closed Tigh Closed Tight _Yes_No Closed Tight _Yes_,No pressure Drop Across _. ..._.._.. osid Closed'N6ht Yes _No I Closed Tight Yes _No pressure Drop Il Check Valve D'. Double Check BackflOW Prevention Asse mblV (DC) .—TE Check Valve N3 Yes _No Closed Lght _Yes _No Closed Tighi sid psid Closed Tight NO Closed Tight Yes _No sld�— psid re Vacuum Breaker Assembly (PVB) or Spill Resistant Vacuum BI Check Valve Air Inlet Valve posed Tight _.•Yes �No Failed to Open_ Yes _No Pressure Drop Across Opened at osid Opened at D,-I osid Closed Tight _Yes_No Closed Tight —Yes—No Closed Tight _Yes._No Describe Para and Yes _No repairs when needed Closed Tight _Yes _No Closed 7lHht _ Pressure Drop Across Final Test Opened at Ps Check Check Valve al psld svkh the limits of the standards. he tested device is functioning �, oin information Provided by me to be correct Date: CERTIFICATION• erti� e_ ''1cO Name (print): Signature: — &...r ramiri ate Number: _