HomeMy WebLinkAbout2014 Backflow Preventers Annual Test r `iry4.
SUMMIT
Mi FIRE PROTECTION BACKFLOW PREVENTERS
SU M M IT MECHANICAL OF MN
jANN�JA�.TEST
COMP ►NI ES 1
CUSTOMER ' JJrt'�� f (. j4 ( r t 1 of I- a t'?
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STREET ADDRESS: 35 7-5 ,lam'r 74\. 6 rr 'n c Rte'' ieti. ai, , r
LOCATION OF ASSEMBLY: CA ,-,N( rl r t)t)1 : t. e t/ f'
TYPE OF ASSEMBLY: RPZ /\ DCV AVB SIZE:
MANUFACTURER: W i 1 V,t ✓t MODEL: 171jr )C L. SERIAL#: w p 9' S 5791-1
CHECK VALVE#2 CHECK VALVE#2 PRESSURE
-, CHEcK VALVE#1 RELIEF VALVE TEST#1 TEST#2 VACUUM BREAKER
BACK PRESSURE CONFIRMATION
leaked did not open leaked leaked air inlet opened at
X closed tight >c closed tight closed tight psi
did not open
Differential pressure Differential pressure Differential pressure check valve:
across check valve -, across check valve across check valve leaked
g_$ psi opened at: , psi psi psi held at psi
ti
Cleaned only Cleaned only Cleaned only Cleaned only Cleaned only
Replaced: Replaced: Replaced: Replaced: Replaced:
rubber kit X rubber kit K rubber kit X rubber kit rubber kites
CV assembly CV assembly CV assembly CV assembly CV assembly
or. or or or or `
disk disk disk disk disk
o-rings o-rings )C o-rings k o-rings o-rings
seat seat seat seat seat
spring X spring X spring springspring
stem/guide stem/guide stem/guide stem/guide _ stem/guide
retainer retainer retainer retainer retainer
lock nuts lock nuts lock nuts lock nuts lock nuts
other other other other other
Differential pressure Differential pressure Differential pressure Air inlet psi
across check valve opened at: psi across check valve across check valve Check
psi psi psi valve psi
Note:ALL REPAIRS SHALL BE COMPLETED WITHIN TEN (10) DAYS
• REMARKS: /t e i)t,t I %t'S 7tPd CI f../.5_,S e
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INSTALL DATE: REBUILD DONE: REBUILD DATE: 2/29 /f
I HEREBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE
OF THE ASSEMBLY
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TESTER'S NAME: dU G r.f"i Z IA •t t CERT. •#: C /t� 2 YSc
_7774)44z/9
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......
TESTER'S SIGNATURE: c .,- DATE: .
575 MINNEHAHA AVE.W 418 GREAT OAK DR. 4208 ENTERPRISE CIRCLE 3026 40TH AVE.NW. ' 760 LIBERTY WAY 4353 NW URBANDALE DR. -
ST.PAUL,MN 55103 WAITE PARK,MN 56387 DULUTH,MN 55811 ROCHESTER,MN 55901 NORTH.LIBERTY,IA 52317 URBANDALE,IA 50322.
651-251-1880 320-257-6390 218-740-4412 507-280-0622 319-665-4330 . 515-867-2424