HomeMy WebLinkAboutBack Flow Preventer CertificationsWhite: CMD / Yellow: Certified Technician / Pink: Customer
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Tester,Certification # -!
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Assembly Test Results W Pass El Fail
Backflow Prevention Assembly Test & Maintenance Report Test #:
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.zt.,Water District/ Authority: ,g, a g ,i -d :1 •,,..,,. Account: Contact Person:
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lz,1 Facility Name: .' , , t'::', r'l .1,. c'''. Contact Phone # :
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l Service Address: ',...) .,_.; S.
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',. Mailing Address:
R.4 Owner o Manager o Contractorg" Other: Contact Person:
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Company Name! Title: /- .:. i Contact Phone #:
Mailing Address:
it Make: t -k-).,-', l'`.1 r Model: *lot cl ,...:.,1 Size:
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Type: IA RPZ1E1 DC 0 PVB 0 SVB 1:1 Air Gap IDAVB 00ther ,
t • 1,,. Location on Property: i,. ,
4Date Installed:/- V 1
•
U2, - •
E•1 (Only if Applicable - Include Previous Serial#) Orientation Service Protection
fil o Replacement Assembly Inlet: Outlet: 4n Domestic JD Containment
*1,4 o New Installation 0 i Vertical Up i 0 o Fire o Isolation
-. -- o Stolen o 1 Vertical Down 1 0 o Irrigation o Containment
.---,
Previous Assembly Serial # J -i —1. Horizontal --). CI o Other By Isolation
--,... .
Line PSI: ":,: 4,1
Initial Test Results
Repaired:
Cleaned:
Re -Test Results
Tightness
Differential
ck#in Ck#2o RVo
Ck#10 Ck#2o RV LI
Tightness
Differential
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ft
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Check Valve #2
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o Leak
p Tight
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disco springo seatu other
o Leak
o Tight
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diaphram-n seato other
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Buffer„,-
(RPZ)
,
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Repaired:
Air Inlet o
Cleaned:
Air inleto
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YCOSIVIrtet5PVB§,
dt. .
f -i' . -, , - 0404 •
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tShutoff
Valve #1
ID Leak gi Tight
soy*/ Open Upon Arrival:o Open Upon Departure: o
Backpressure Exists?
Yes 0 No o
...Shutoff
Valve #2
o Leak a Tight
SOV#2 Open Upon Arrival o Open Upon Departure: o
Cause:
‘.4.Assembly
Concerns:
Test Procedure:
•:;'
Comments: - •
v,
(only if applicable)
Installation?
) r., I
ABA 6
.t
Incorrect o
Incorrect Use? o
— ,
Turn Off Date: / / Turn On Date: / /
Turn Off Time: Turn On Time:
to
2,5 Alarm Company/Fire Department Notified:
rit
,..r.7.P Person Notified: Contacted By:
tg2 Turn Off Date/Time: Turn On Date/Time:
gk
.0, 7 /,,
..Test Gauge Make: (:.,.,./ Model: L
. :':.,"P'-',) ast Calibration Date: -";,::: /Ji.'? /
„ , ,, ......
...-'7rherby certtatt1164,1sOlitiOng/ hefciffVelVeMOV#VeregOV42yheW the'enTiiiiirtieli),fthe:paiibn:InVifiloliwere found and that thetest wasdone according tothe '
I above and the test reatings ix e-,are,true.,ancPecciitate4oltti61.06Stofjrnylabill — _
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rl Tester Name: 6.,,,i j'l '''' S ,r, ,1 '''':' I' , (Please Print)
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(Tester) --r, . . ,
, , ,, . ,, (Customer)
Signature: : ::,,, v .e.:....// i2,„,,. ,.. k-..,,: y!y., Signature:
White: CMD / Yellow: Certified Technician / Pink: Customer
White: CMD / Yellow: Certified Technician / Pink: Customer
Assembly Serial #..`
Test DateITinne « . 4 1 4 ` * :w `
;GaugeSerial # r .4.
District Required info } _ ,
ester Certifacation #' n
Date Cer it#10:19r1-5,„_x ares ..<E � -y .
Assembly Test Results
Backflow Prevention Assembly Test & Maintenance Report Test
®
Pass El Fail
#:
(Please Print)
Water District) Authority: P �:"a' Account Contact Person:
:=- FacilityName:f- , . ,°y` Contact Phone # :
7.' ._ Service Address: r ' �' ..,'1,."
a' Mailing Address:
Owner ❑ Manager o Contractor of-, : Other: Contact Person:
vi Company Name/ Title: `" ' Contact Phone # :
`Mailing Address:
Make: '''", .; Model: Size:
Type: 'q, RPZ ❑ DC ❑ PVB ❑ SVB ❑ Air Gap ❑AVB ❑Other ,
Date Installed ,Iii.,/-,,.., Location on Property: 1:1-y-) t '. J. , „',,
(Only if Applicable Include Previous Serial#) Orientation Service Protection
i
,a e
auge eria
ifrict FeqUire
DateCfidtiop Expires
esteriC idatiOn,
Prt
Assembly Test Results ,,E1Pass El Fail
Backflow Prevention Assembly Test & Maintenance Report Test
(Please Print)
ioga .,.-„.,,.
Pal Water District/ Authority: 4_,.!),"7.)4; -7 ;.„„,:. Account: Contact Person:
it'i el ,
-=,,-- Facility Name: t ,.., t e -v.. e.: ,,::::. ( c:.-.:.;;,_ (.:,',., 1 ''',' --- ', -:J''' Contact Phone # :
got/•
kla Service Address: `,-). 0 3 ...,. '::- r....,,C,... i ,!-'; i d /
*4{,,'
titil Mailing Address:
• Owner n Manager 0 Contractor) m Other: Contact Person:
go, Company Name/ Title: .((, Contact Phone #:
1,7711 Mailing Address:
te441
'0-4 Make: , t''' , c --. Model: ,4., c ' 1_ ' , , ', ,) Size:
24 Type: ii RPZ X DC 0 PVB LI SVB 0 Air Gap 0AVB 00ther
.
,Date Installedm - '-i i - e.,..$ Location on Property: yr\ v t A e • ,y' r: .,..,, ',r ::, i ' k:i , e''' ,:-!„ e"
40 (Only if Applicable - Include Previous Serial#) Orientation Service
,Protection
ZEV..1
'gnu n Replacement Assembly Inlet: Outlet: IS Domestic ,I4 Containment
lom ,
, A Er New Installation o 1 Vertical Up T o 0 Fire Eilsolation
4.A 0 Stolen
VA 0 Vertical Down .1. o o Irrigation El Containment
V4 Previous Assembly Serial # LI: Horizontal , o Other By Isolation
,G!'
0:
_.,
) Line PSI: CI -
Initial Test Results
Repaired:
Cleaned:
Re -Test Results
Tightness
Differential
ck#10 Ck#2o RVo
Ck#lo Ck#2o RVo
Tightness
Differential
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T-t-Wei.o.c ,
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sCP 'A Tin zi,,qs p ..9
o Leak
Check Valve #2
.Ok#2: RPZ, DC)
0 Leak
T Tight
1 ,
ck#2
disco spring° seato other:
o Leak
o Tight
6
4,
V'''
1iefVaIve
A
RV
lap ra eato ther.
- ,' ,.
It
Buffer
(RPZ)
Repaired:
Air Inlet o
Cleaned:
Air Inleto
'Aird.kilet 6
(Aielowp,ve,s ---v-
---t
,,- -
igt11e
.-.:
9POS IVO E! °t
Shutoff Valve #1
o Leak I'D Tight
sov#i Open Upon Arrival:o Open Upon Departure: o
Backpressure Exists? Yes 0 No o
Cause:
Shutoff Valve #2
0 Leak ,r Tight
SOV#2 Open Upon Arrival 0 Open Upon Departure: n
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
Installation?
ABPA 0 ASSE
Incorrect i:
4. incorrect Use ? o
a-
Turn Off Date: / / Turn On Date: / /
Turn Off Time: Tum On Time:
..,
Alarm Company/Fire Department Notified:
,.t..
-.'.7..0 Person Notified: Contacted By:
,04
t Turn Off Date/Time: Turn On Date/Time:
!‘...k.r4Test Gauge Make: ',.., 4. to' -4-.', Model:":,:',, 7:,,. Last Calibration Date: 2, /::'(..)
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testing,Company one:. -.Na Phone
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kTester Namr--.' il 1; \ ,f4 '''''fi, f -'--i '
•.,'...1, • (Please Print)
:-:,--*-' (Tester) --, (Customer)
, I) C-. •/ 1
Signature: i i ' , .-„ 6, i . :j,. ,:.,,, • , , Signature:
White: CMD / Yellow: Certified Technician / Pink: Customer