HomeMy WebLinkAboutBACKFLOW PREVENTER REPORT 8/23/2016 AA, PRO
..... 400, PLUMBING, SEWER & 952-890-4455 . 651-452-9888
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1. DRAIN CLEANING 952-469-6999 • 1-507-663-1765
0 ' 1:44//1111/1 i .0
Residenno'c7',Commercial 24149 Highview Avenue• Lakeville, MN 55044
Don't Cal 1 a Cowboy,Cal 1 a Pro
ANNUAL TEST - BACKFLOW PREVENTORS
Customer:
Mailing Address:
Property Owner: Pei 4't---i (31-,, -41
Pi/i r /At 1,•,,,t
Street Address: '''., 35-0 si,,,,,re itA. / 410 E.
Mailing Address:
Location of Assembly: .
1 if
TYPE OF ASSEMBLY 1 ,RPZ CDCV ›PVB riSVB SIZE: i
MANUFACTURER: A 0 ti It ti MODEL: pvip) i-ti4 SERIAL#: 11- 000/
Check Valve #2 Check Valve#1 Check Valve#2 Pressure Spill-Resistant
Relief Valve Back Pressure In Direction of In Direction of Vacuum Vacuum
Test Flow Test Flow Test Breaker Breaker
Opened at: Leaked 0 Leaked I Leaked I I Air inlet Air inlet started
psi opened -t: opening at:
did not open I Closed Tight_ Closed tight I Closed tight LII psi
Differential pressure Differential pressure Did not open Did not open
across check valve across check valve check valve: I check valve: I
psi psi Leaked 0 Leaked _
held at psi held at psi
Cleaned only I I Cleaned only I I Cleaned only Cleaned only I Cleaned only— Cleaned only P
Replaced: Replaced: Replaced: Replaced: Replaced: Replaced:
Rubber Kit Rubber Kit Rubber Kit Rubber Kit all Rubber Kit El Rubber Kit
Assembly Assembly Assembly Assembly II Assembly . Assembly
(RV) (RV) II (RV) Il (RV) (RV) III (RV)
II
Disc Disc U Disc I Disc a Disc ' Disc
Diaphragm Diaphragm al Diaphragm I Diaphragm U. Diaphragm Diaphragm
Seat H Seat Seat Seat IIII Seat : Seat a
Spring ' Spring Spring Spring Spring 1 Spring _
Guide Guide Guide Ill Guide MI Guide Guide 11111
0-rings , 0-rings 0-rings 0-rings 0-rings .III 0-ringsal
Other Other Other Other I Other III Other
Opened at: Closed Tight El Differential pressure Differential pressure Air inlet Air inlet starting
psi across check valve across check valve psi to open
psi psi Check valve psi
psi Check valve
psi
Opened shut off#1 I I Opened shut off#2 E Water Pressure Test Kit Serial #
Remarks:
I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly.
Tester's Name (Print) 7'4-1 Eirevtoi Cert.
Tester's Signature Date -0-)--- Icy Time