000 (2) BACKFLOW PREVENTION ASSEMBLY TEST REPORT
Water Purveyor Water Meter No. Permit No.
I ,. (L Z. 7 i j ZZ- 3 /
SV PVB Manufacturer Size Model No. Serial No.
`RP DC W 1 1 tC.r n{5 i ,i `j % X G, • -• - 8 2-- l-F / S
Owner Person to Contact Phone No.
Address City, State,Zip
y 4, o /I i, _,"1-c,-/f"r� t i'• L, -r\ .,- ; = r-, ,% , : ``. SL o
Owner Representative Person to Contact Phone No.
/i i // ,VJ L _Q/ 3 -1,.'oi
Representative Address Assembly Address
✓ i. L)i
On Site Location of Assembly ` Line Pressure
i
What is the Primary Business or Service Performed Is this a new installation? fiit Yes 0 No
at this location? Does this assembly replace another? No
0 Yes Serial#
Purpose: Secondary/Containment* Primary/Point of Use 0 Fire System 0 Landscape D• Potable/Domestic ❑
Pressure Vacuum
Double Check Valve Assembly OR Reduced Pressure Principle Valve Assembly Breaker
Back Pressure Y N
DIFFERENTIAL AIR INLET OPENED
CHECK VALVE #1 CHECK VALVE #2 PRESSURE RELIEF AT PSID
VALVE LEAKED Y N
1. CLOSED TIGHT Y N 1. CLOSED TIGHT Y N OPENED AT CHECK VALVE HELD
INITIAL TEST , y PSIDx. PSID ? <4' PSID AT PSID
2. LEAKED Y N 2. LEAKED Y N DID NOT OPEN Y N 2. LEAKED Y N
CLEANED Y N CLEANED Y N CLEANED Y N CLEANED Y N
REPLACED RUBBER KIT REPLACED RUBBER KIT REPLACED RUBBER REPLACED RUBBER
Y N Y N KIT Y N KIT Y N
cc
DISC Y N DISC Y N DISC Y N DISC Y N
d SPRING Y N SPRING Y N SPRING Y N SPRING Y N
GUIDE Y N GUIDE Y N GUIDE Y N GUIDE Y N
OTHER Y N OTHER Y N OTHER Y N OTHER Y N
SHUT OFF VALVE# REPAIRED 0 REPLACED 0 BOTH OK ❑
OPENED AT
1. CLOSED TIGHT Y N 1. CLOSED TIGHT Y N AIR INLET PSID
FINAL TEST PSID PSID PSID CHECK VALVE PSID
REDUCED PRESSURE
This report is certified to be true.
' INITIAL TEST (IF FAILED) BY: CERTIFIED TESTER NO. DATE FAILED TEST KIT SERIAL#
REPAIRED (IF NECESSARY) BY: CERTIFICATION NO. REPAIR DATE
FINAL TEST BY: / 'I CERTIFIED TESTER NO. DATE PASSED TEST KIT SERIAL#
/te a. -"i !.. ^ C» ,_, z_ U !
COMMENTS: _Annual _Annual w Repair—Repair Only (C of 0_ Hydrant Meter _Temp. Construction
j_ .7 J 7
L L r-b ; ,ji E.4-, /\,-, ;.__ ;--
BPDI
Backflow Prevention Device Inspections, Inc. 3831 E. Grove Street. Phoenix AZ 85040
PH: 602-788-5411 FAX: 602-788-6104
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
Water Purveyor Water Meter No. Permit No.
SVE1- PVB Manufacturer ' Size Model No. Serial No.
RP DC ,",ci i / .G( tJ' .) / % X 2--- _ k L < 5 i o
Owner Person to Contact Phone No.�
r_ H'�/E_/�/ A',/ i- : .,F ,� 1 ,�c-"/Z <,c' /?- - /i s.'
Address City, State, Zip
9 C, ,--) nl . r` _,'1-r /1 ; / / '7 _//) ii-/ , �P 0( 2 I-
Owner Representative — Person to Contact Phone No.
R//% '(..9c')-/
Representative Address Assembly Address
J' L.) 4. 'J C-I-1). ' ;r=-f 1
On Site Location of Assembly Line Pressure
IZ
What is the Primary Business or Service Performed Is this a new installation? 1 Yes ❑ No
at this location? Does this assembly replace another? VT No
El Yes Serial#
Purpose: Secondary/Containment 0 Primary/Point of Use ❑ Fire System 0 Landscape El Potable/Domestic 0
Pressure Vacuum
Double Check Valve Assembly OR Reduced Pressure Principle Valve Assembly Breaker
Back Pressure Y N
DIFFERENTIAL AIR INLET OPENED
CHECK VALVE#1 CHECK VALVE#2 PRESSURE RELIEF AT PSID
VALVE LEAKED Y N
1. CLOSED TIGHT Y N 1. CLOSED TIGHT Y N OPENED AT CHECK VALVE HELD
INITIAL TEST PSID PSID PSID AT PSID
2. LEAKED Y N 2. LEAKED Y N DID NOT OPEN Y N 2. LEAKED Y N
CLEANED Y N CLEANED Y N CLEANED Y N CLEANED Y N
REPLACED RUBBER KIT REPLACED RUBBER KIT REPLACED RUBBER REPLACED RUBBER
Y N Y N KIT Y N KIT Y N
Q DISC Y N DISC Y N DISC Y N DISC Y N
1.11 SPRING Y N SPRING Y N SPRING Y N SPRING Y N
GUIDE Y N GUIDE Y N GUIDE Y N GUIDE Y N
OTHER Y N OTHER Y N OTHER Y N OTHER Y N
SHUT OFF VALVE# REPAIRED El REPLACED 0 BOTH OK El
OPENED AT
1. CLOSED TIGHT Y N 1. CLOSED TIGHT Y N AIR INLET PSID
FINAL TEST PSID PSID PSID CHECK VALVE PSID
REDUCED PRESSURE —
This report is certified to be true.
INITIAL TEST (IF FAILED) BY: CERTIFIED TESTER NO. DATE FAILED TEST KIT SERIAL#
REPAIRED (IF NECESSARY) BY: CERTIFICATION NO. REPAIR DATE
FINAL TEST BY: j.- CERTIFIED TESTER NO. DATE PASSED TEST KIT SERIAL#
:L.--1-1,. -,* .T.L 5 - - 2._:-. L. ", / --/ // _.
COMMENTS: _Annual _Annual w Repair—Repair Only C of 0 Hydrant Meter Temp. Construction
•
BPDI
Backflow Prevention Device Inspections, Inc. 3831 E. Grove Street, Phoenix AZ 85040
PH: 602-788-5411 FAX: 602-788-6104