HomeMy WebLinkAboutBackflow Preventer Test
4715.2260
Annual Testing
of R.P.Z. Valves
BACKFLOW PREVENTER TEST REPORT
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MAKE AND MODEL OF gt;V.ICE
f-(..CUl ?, ("t)
LOCArION OF OEVICE:
ZIP
TELEPHONE NO.
DATE: r/tt:crr
SERIAL NO.# or 9u;
:J -,
~ ~'rJ.... Wo..ct Yu-t-d
\
CHECK VALVE,l CHECK VALVE '2
SIZE
~
TEST
BEfOtE
REPAIR
DESC~IBE
REPAIR
FINA.
TEST
MATE RIALS
USED
CERT! F ICATlON:
I hereby certify the foregoing data to be correct and that the tested device is
functioning within the limits of the standards.
FIRM INAMEiAk2S1'~ ADORESs31'f6-?lIJu4a-tc/t1 five #/-iki~,IJ1/V
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BY r'-'Hf{/.J~'""........ TESTER'S CERTlFICATlO/l No.1J~{L TEL. NO.v.17-XJ1-
· . Lf781
LEAKED ( ,J
CLOSEO f")
LEAKEO l )
CLOSED ~
PRES. DIF.
ACROSI n
CHECK .. ;
/i\\"
1011
PRES. DIF.
WHEN RELIEF
OPENS
psi
STRAINER
Lr
NONE \ "<l )
CUlO ( )
~
LEAKED l )
CLOSED ( )
LEAKED l )
psi
psi
DAlE
REMARKS
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