Backflow Testlit-
Water Purveyor: DM Backflow Testing 2,c
E L w\P.O. Box 11082 • Tacoma, WA 98411
New 1 Backflow Prevention Assembly
Existing
Test Report
Replacement 253-227-8858
NAME: E Go /11)/1)C - I .) -r 2 6 FILE NO:
v ? 0 coSERVICEADDRESS: rr d c - % ' -, L--y(2// -'.,
A
Street City Zip
LOCATION: Pt ( .... ,,y; 5',i(f Ik. c ,w-, r„..-,(2-11-e.---
CROSS CONNECTION CONTROL FOR: r 1 0 61% )/-, TYPE ASSEMBLY: AJC V
MANUFACTURER: !1 `-MODEL: SIZE: SERIAL NO: /11
INITIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
Line Pressure
Pressure Drop Across Pressure Drop Across
No. 1 Check Valve(A) _ psid No. 1 Check Valve(A) psid
Relief Valve Opened (B) psid Relief Valve Opened (B) psid
Buffer(C) =(A-B)psid Buffer C = (A-B) psid
RPBA No. 1 Check: Closed tight No. 1 Check: Closed tight 0
Leaked 7 Leaked 0
No.2 Check: Closed tight No. 2 Check: Closed tight 0
Leaked Leaked
Minimum AG Separation: Yes No Minimum AG Separation: Yes No
Passed Test: Yes No Passed Test: Yes No
Line Pressure 5-
No.No. 1 Check: Closed tight 7 /. _ psid No. 1 Check: Closed tight psid
DCVA Leaked Leaked
No. 2 Check: Closed tight psid No. 2 Check: Closed tight LI psid
Leaked 0 Leaked 0
Passed Test: Yes k No Passed Test: Yes No
Line Pressure
Air Inlet:Opened psid Air Inlet:Opened psic
PVB
Failed to Open ElFailed to Open
Check Valve: psid Check Valve: si::
Leaked 0 Leaked
Passed Test: Yes No Passed Test: Yes No
AG Minimum Separation: Yes No PLEASE RECORD REPAIR OR CLEANING
INFORMATION IN SECTION BELOW
IS THIS A PROPER INSTALLATION? Yes X No
Water Service Found: On Off Water Service Left: On X Off
REMARKS:
Test Equipment: Make /4 Jo,e T-/" Model tYq)• 1 Serial# 06 / ( adz Accuracy Verification Date I' / '
r /–)
Assembly Tested: Satisfactorily Xc Failed
I CERTIFY THE ABOVE REPORT TO BE TRUE:
I certify this report is accurate,and that I have used WUC 246-290-490 approved Test Methods and Test Equipment
Certified Testers'Tvned or Printed-Naine Phone No. -,
Initial Test By Cert No. j' 1 I Date 29 - `F
Signature
Repaired By: Date
Repair Test By: Cert No. Date
Signature