HomeMy WebLinkAboutDrain Pro, Inc. - Backflow Preventor Test �� PR Q PLUMBING, SEWER 952-890-4455 • 651-452-9888
�� �2 DRAIN C�EANING 952-469-6999 • 1-507-663-1765
Q � " • � ' " • '"' 24149 Highview Avenue • Lakeville, MN 55044
DonY Call a Cowboy, Call a Pra
A NUAL TEST - BACKFLOW PREVENTORS
Customer: C` �-� . tv � k� � J F� ��:�
Mailing Address: v s �j J � �t��,� :i ! y S'f" � ,� � � ,
Property Owner:
Street Address:
Mailing Address: `
Location of Assembly: �c.� 5� r�•-- �. t"
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TYPE OF ASSEMBLY �PZ ❑DCV OPVB OSVB SIZE: I
MANUFACTURER: ;1+�.� !` , `�``'�. MODEL: � 7s � r SERIAL #:
Check Valve #2 Check Valve #1 Check Valve #2 Pressure Spill-Resistant
Refief Valve Back Pressure In Direction of In Direction of Vacuum Vacuum
Test Flow Test Flow Test Breaker Breaker
Opened at: Leaked ❑ Leaked ❑ Leaked ❑ Air inlet Air inlet started
�psi opened at: opening at:
did not open ❑ Closed Tight � Closed tight �.. Closed tigh� psi
� L Differential pressure Differential pressure Did not open Did not open
' I across heck valve across check valve check valve: ❑ check valve: ❑
� � si �•�'� psi Leaked ❑ Leaked ❑
held at�psi held at psi '
Cleaned only ❑ Cleaned only ❑ Cleaned only ❑ Cleaned only ❑ Cleaned onty ❑ Cleaned only ❑
Replaced: Repfaced: Replaced: Replaced: Replaced: Replaced:
Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit
Assembly Assembly Assembly Assembly Assembly Assembly
(RV) (RV) (RV) (RV) (RV) (RV)
Disc Disc Disc Disc Disc Disc
Diaphragm Diaphragm Diaphragm Diaphragm Diaphragm Diaphragm
Seat Seat Seat Seat Seat Seat
Spring Spring Spring Spring Spring Spring
Guide Guide Guide Guide Guide Guide
O-rings O-rings O-rings O-rings O-rings O-rings
Other Other Other Other Other Other
Opened t: Closed Tight Differential pressure Differential pressure Air inlet Air inlet starting
____���psi across check valve across check valve psi to open
�� U n si �•`'1 psi Check valve psi
psi Check valve
psi
v
Opened shut off #1.� Opened shut off #2� Water Pressure ,�,;Z est it Serial #
Remarks:
I hereby certify fhat this date is accurate and reflects the proper operation and maintenance of the assembl�
Tester's Name (Print) 'T'�.v y �����'� Cert. aC�UK ���" C
Tester's Signature � Date � ?6 �L�" Time �°