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Pressure Vacuum Breaker Assembly (PVB)
ASSE Standard#1020 Field Test Report
Owner of Property Patrick&Jenni Drury
Address 17837 Cleary Trail SE p 55372
City Prior Lake
State MN Zi Code
Occupant of Property (if different from owner) ,
Occupant Address State Zip Code
City
A olio Model#: PVB4A
Manufacturer of Assembly: p Serial#:'A014788
Size of Assembly: 1�� y Application: Front left corner of house, irrigation
Location of Assembly and Equipment or S stem
Test Equipment: 845 Serial#: 02160302
Manufacturer: Mid-West Backflow Model#:
Calibration Date:2-3-16751_2j1____
Date test was performed:
10-21-16 Time test was performed: 1:00 Static Line Pressure:
Air Inlet Valve
Check Valve Shut Off#2
Leaking 0 Leaking 0
Failed to Open Closed Tight 0
Initial Test Opened at psid Pressure Drop Across Closed Tight 0
Check Valve#1 psid
Describe parts and 1111111
repairs when needed
Leaking ❑ Leaking 0
Opened at 2.4 psid Closed Tight Q Closed Tight
Final Test Pressure Drop Across
CI
Check Valve#1 1.8 psid
Assembly Final Test
Certified Tester(print)Scott Ludwig Performance
Address 2200 West Highway 13
Pass
City Burnsville State MN Zip 55337 _
II
Phone#: 9527671000 Fail
License#:
BF064036 Certification# ASSE#30730
El
VW Date: 10-21-16
Signature
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