Backflow TestWater Purveyor DM Backflow Testing
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P.O. Box 11082 • Tacoma, WA 98411
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Backflow Prevention Assembly
NeNesting Test Report
ExiReplacement 253-227-8858
NAME: 1 J t. ! `-1 H ) 07)F - ` J T 1 _
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FILE NO: -
SERVICE ADDRESS:J 5`, /p, S—_ Cf 7 C "'
Street City Zip
LOCATION: f ` 01 1 j . (IP cv„ 1* Tv ,., r., rv4, +-ar
CROSS CONNECTION CONTROL FOR:j tr t t l` f? 1, c TYPE ASSEMBLY: C 1
MANUFACTURER: P /7 r' , MODEL:
J
SIZE: / SERIAL NO: f (–I / I R 7
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 i J No. 1 Check: Closed tight
Leaked Leaked ni
No.2 Check: Closed tight No. 2 Check: Closed tight
Leaked i Leaked
Minimum AG Separation: Yes No - Minimum AG Separation: Yes No _
Passed Test: Yes No Passed Test: Yes No _-
Line Pressure J
No. 1 Check: Closed tight 0 psid No. 1 Check: Closed tight psid
DCVA Leaked Leaked LI
No. 2 Check: Closed tight 9 psid No. 2 Check: Closed tight psid
Leaked Leaked
Passed Test: Yes K No _ Passed Test: Yes No
Line Pressure
Air Inlet:Opened psid Air Inlet:Opened psid
PVB
Failed to Open ElFailed to Open
Check Valve: psid Check Valve: psid
Leaked Leaked 1
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 ?r Off Water Service Left: On X Off
REMARKS:
Test Equipment: Make /14 /It),034' Model CVS- ? Serial#O C'->/ "V 1 Accuracy Verification Date ///7 ,' s
Assembly Tested: Satisfactorily X 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
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Certje -Testers&-Typed ea name
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Phone No. /
Initial Test By _Cert No.33 /G
21 Date y/2 Si
Signature
Repaired By: Date
Repair Test By: Cert No. Date
Signature