15410 Ellie Ct SE Backflow TestWater Purveyor: DM Backflow Testing
P.O. Box 11082 • Tacoma, WA 98411
New Backflow Prevention Assembly
Existing
Test Report
Replacement 253-227-8858
NAME:
j
FILE NO:
SERVICE ADDRESS: l T(,'Io E I ! . ..e,4r/"
l
Lt71 ) )
Street City Zip
LOCATION: r3-t11 t 'I /,41,e 1J-l'lc-
CROSS CONNECTION CONTROL FOR: V``i a`I-1'°1 TYPE ASSEMBLY: IN-1
MANUFACTURER:
f.-
MODEL: I. SIZE: /SERIAL NO: A/ '/ 154F) )
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 0 No. 1 Check: Closed tight IL
Leaked Leaked
No. 2 Check: Closed tight No. 2 Check: Closed tight .
Leaked Leaked C
Minimum AG Separation: Yes No Minimum AG Separation: Yes No
Passed Test:
v/,
Yes No Passed Test: Yes No
Line Pressure 5
C
No. 1 Check: Closed tight 2r
psid No 1 Check: Closed tight psid
DCV Leaked Leaked
No. 2 Check: Closed tight J p r
psid No. 2 Check: Closed tight psld
Leaked Leaked H
Passed Test: Yes _i No Passed Test: Yes No
Line Pressure
Air Inlet:Opened psid Air Inlet:Opened psid
pV6
Failed to Open Failed to Open I I
Check Valve: psid Check Valve: psid
Leaked Leaked LI
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 No /
it/
Water Service Found:
0 ,, 01C1 r_
Cin Off 7' Water Service Left: On Off V
REMARKS: V
Test Equipment: Make kV" 11/4 Model g44'_ 5—Serial# nr/) 223 D Accuracy Verification Date // '7
Assembly Tested: Satisfactorily Failed
I CERTIFY THE ABOVE REPORT TO BE TRUE:
I cerci th' ..report is a¢c irate that I have used WUC 246-290-490 approved TiAt e h Test i ment
Certir hers' ype or Print me 6 y re.
Phone N% /
Initial Test By Cert No.
V
Date
2.
Signature
Repaired By: Date
Repair Test By: Cert No. Date
Signature