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Untitled (14) Backflow Device Test Report R�rmit#: Date: . Backflaw: ❑Reg ❑Not Reg U Lic exp O Residential Commercial O New Assembly _ Existing Assembly f'I Repair of Existing Assembly Job Address: �� . . 7,��(9 System Owner: �oss S,��� �p� 3� , � Assembly Location: 1d � � - b� '-!1F E3r�Cl<��_C4^v�%REO�`Ei�l'lf)(�!ti;y�i(��(1�1H(...`d 1_I`�TEC)SEL��Vi Ht��:-�f�f �Pd��f�r �il i��D P��1C}�v8,-�.)P,IT?IN���I� � .(_1t,1, � •,i`E •,'�Ai R�(',UL�%��'..CiNS Y1NG E;>C'f NTI(I�Ci TCi E3F�PERl1T�r�J(;`v"i'I 1�;'!">.i:;�,l -'i ii31. <=F::z( # '(F:;� TYPE OF ASSEMBLY nReduced Pressure Principle � Pressure Vacuum Breaker �U Double Check � Atmospheric Vacuum Breaker Manufacturer: l��� Serial Number: ���'�3 Model Number: � � � Size: a i Reduced Pressure Principle Assembiy/Doubie Check Valve Assembly Pressure Vacuum Breaker 1st Check 2"d Check Relief Valve Air Inlet Check Valve Initial Test DC-Closed Tight Gosed Tight Opened At: Opened At RP- psid psid psid Leaked psid Leaked Did not open Leaked �,e�5 �C� Repair Re�irS�lAA�at�rials Used ��w �'�� CO(.I�S DG Closed Tight Closed Tight Open At Open At: Test After Repair RP- _�sid psid psid psid Pass ❑ Fail p Certified Tester: "� Contractor Name: 'I �1 Li,� ' Tester#: � ,,�Contractor Address: ^ T _ (� Signature: Contractor Phone: ���'�,2C�-q3�j Revised 10/12 Backflow Device Test Report P�rmit#: Date: BadcNow; ❑Reg O Not Reg ❑Lic exp ❑ Residential Commercial O New Assembly Existing Assembly ❑ Repair of Existing Assembly Job Address: - �_ T � � R System Owner: � oSS . �_SK�tt o'2�� •�s a Assembly Location: ..�'"/V� 1�- f0 .et'-t �j � � TtiF SA::KFLO�E�;UL��i�(.iN��-�ND 1.����E� TI(I��FII�f;�C'�EF�€�f L�,d�T�E �:1l��D��(C} I�,I�dT�lN,��fi 7�L�! (k C"�1;'r '"'f �� nr c,� � ' _ ,hTIfJ(�;'v;'iTh�'��`�C�; ,4 � ,:�31.. F,i�;�frf 1(_fi�; TYPE OF ASSEMBLY � Reduced Pressure Principle n Pressure Vacuum Breaker �Double Check Atmospheric Vaa�um Breaker \ ( �-i :���'J Manufacturer: �/(� � ���j Serial Number: __ _ � Model Number. I 5 � ]�,L Size: � ~ Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure vacuum Breaker 1st Check 2"d Check Relief Valve Air Inlet Check Valve Initial Test DC—Closed Tight Closed Tight Opened At: OPened At RP- psid psid psid Leaked psid Leaked Did not open Leaked 'V��S �Z't'�Repair t2eaair�lMBterkals Use�� �l4 -�e�'Co[.�'s DC-Closed Tight Closed Tight Open At: Open At: Test After Repair Rp- ____Qsid psid psid ps�� Pass O Fail O Certified Tester: 21,�, "�5 Contractor Name: ' � � ' - , Tester#: Contractor Address:� , � s !f c7 Signature: ContractorPhone� ��p�� ��'93� Rev+sed ld/12 Backflow Device Test Repvrt P�rmit#: Date: B�dtflow: �Reg ❑Not Reg ❑ Lic exp O Residentiai Commercial O New Assembly Existing Assembly ❑ Repair of Existing Assembly Job Address: � �o Lv1� � � System Owner: f(,t+�►1 {�.� S � '$D� c�,l�'.S J�� Assembly Location: . � 1S (' ',�„ „�-� Tf-1- rir'��:;f<F�OVJ F�i�=,��,tE�1 TIf)N 1i:�5�y�MH�.Y�_iSTEC)[3��t71'�.'HfaS�'st tP,t I � 1�I b��lfi',1%�\l:'•ITµI(�1-�i �_5`�C�i,E f ,�:1 „.��i: F�F'�UI��:��N�ANG E;;CC F?�Tiil �:[i TO E3F GPEF..t�.TltlC�'v•il T�-„d AC;� ! �' ="�`,i;t _ ��F'�, I Ir_�t;'� TYPE OF ASSEMBLY � Reduced Pressure Principle � Pressure Vacuum Breaker � Double Check !a�"�,(�-�—Di( a Atmospheric Vacuum Breaker Manufacturer: Serial Number O0(�� 7 �3 ��G ,� Modei Number: � Size: � Reduced Pressure Principle Assembly!Double Check Valve Assembly Pressure Vacuum ereaker 1st Check 2od Eheck Relief Valve Air Inlet Cher,k Valve Initial Test DC—Closed Tight Closed Tight Opened At: Opened At: RP- psid psid psid Leaked psid Leaked Did nok open Leaked Repair R�pair'slMat�rials Usedj DG Closed Tight Closed Tight Open At: Open At: Test After Repair RP- _�sid sid P psid psid � �� ^ �S Pass [8' Fail ❑ i Certified Tester: t- Contractor Name: t � i .er� � Tester#: � � � Contractor Address: {f _ � �-���� Signature: Contractor Phone: ����-2 y'g3��j Revised IOJ12 Backflow Device Test Report Permit#: Date: ' Bac�flaw: 0 Reg ❑Not Reg ❑Lic exp ❑ Residentiai Commercial O New Assembly _ Existing Assembly ❑ Repair of Existing Assembly Job Address: . O " , (.,� System Owner: ( . �; S��v � S � �� . ..... � ' � .. Assembly Location: . � �,� r�a�.���ci;F ctin.w:,=�;��,�r�c�r�r�s5r_M��_���t_,srFr;aF�oG^;����=r ��,� �� �>>r r��.1ir� ,,�i��^�Tai�a-r> >.>� r_;! �r r� �:;., ;�€ �. F'F,�l)I,'1T!ON;%�NCi iS C,f F'TI(-l�Ci T;)�;F(iF3ERF,TIPE(�'+Pi'i1F-.?V t^�.i:; ! -'';�i?[_ -'?.R�.f�;�E 1 f tiz;� TYPE OF ASSEMBLY nReduced Pressure Principle � Pressure Vacuum Breaker � Double Check � Atmospheric Vacuum Sreaker Manufacturer. ��rS�t/ Serial Number: 9�� � Model Number: ' � � " � 'lG Size: ��y Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum Breaker 1st Check 2"d Check Relief Valve Air Inlet Check Valve Initial Test DC—Closed Tight s2��+' Closed Tight • Opened At: Opened At RP- psid psid psid Leaked psid Leaked Did not open Leaked Repair Ret�air51�A8te+-i�f9 iJs�d: DC-Closed Tight Closed Tight Open At: Open At: Test After Repalr RP- _psid psid psid psid � __/ � � 2 0 `�J Pass l8� Fail O 1 Certified Tester. � �C" ` Contractor Name: � �� eF,� Tester#: r Contractor Address � :Q f I -- .�f 5 '�o y� Signature: Contractor Phone: _ ��,�-�.��- ��'�� Revfsed 10/12 Backflow Device Test Report P�rmit#: Date: Backflow: U Reg ❑Not Reg 0 Lic exp O Residential Commercial O New Assembly Existing Assembly f"I Repair of Existing Assembly Job Address: 9 System Owner. f C- L ;�pJ " � � Assembly Location: _ G �� �O � ',� �,,(�,1 TF�iE 6IOCl<FLGV^J r�'REVE.'�J I10�[F4S�iEr�.MF3l_Y I.(STEC7 kiEL��1`L�r1F�S'S(�Ef�!T� .`,7L D?�^J�fVi.�,IP,IT:I�J�l�_ ��"�=(�7.,f F�� L�Y ""}it REC3U(��?It)N,:a AND IS C;C-F?TIFII:G'TO E3E OPER,n.TICJC"V`;'f I}-?�'v P.i;,i � `�i-;I_ t�`,R,`t'i E 6 r:�;; TYPE OF ASSEMBLY DReduced Pressure Principle � Pressure Vacuum Breaker � Double Check �e,(,—�D( � Atmospheric Vacuum Breaker Manufacturer: f � Serial Number: DD��,7 � rp rl Model Number: �lZ�� SiZe: e Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum Breaker 1st Check 2"d Check Relief Valve Air Inlet Check Valve Initial Test DC—Closed Tight Closed Tight �_ Opened At: �Pened At: RP- psid psid psid Leaked psid Leaked Did not open Leaked Repair Reaai�slM�tetials iJs�° DG Ciosed Tight Closed Tight Open At: Open At: Test After Repair RP- _�sid psid psid ps�� � _�.� �S pass [� Fail ❑ �t �/'' Certifred Tester: P�1� Gontractor Name: :/' � (��lt. � � Tester#� D �(Q�'1 _ ContractorAddress: " (.(, „� � _ � 'r���� Signature_ Contractor Phone� � ��' o�.��� 93 �j Revised 10/Y2 Backflow Device Test Report P�rmit#: Date: Badtflow: ❑Reg ❑Not Reg ❑ Lic exp O Residential Commercial O New Assembly Existing Assembly ❑ Repair of Existing Assembiy Job Address: . �o - 7 �U System Owner. .5't"�c,cvw� �Cc �OI 5 �/C S�•�!c- ���� 1.� S 7 �� Assembly Location: . QPO ��� ��fl �� '�' � THF tir'iGKFL04'1,'F�'REVEN��lIC)N s�:��irMBl...1'L.ISTEC�BE���b''�i HF�:�i t3C -Cd�I�E �iTl:f7",�!(�"dl�.l',1T��1�1'�,�i�� > .0���,1f-'C" _;Y ••,�_:: REC;(.J',1:,vtiS.A_C�C�IS(;f:F:.T�FI �D TO f��C)PER-I�S1��C t'�il l !��,",`i.;.,k �"rk�i_ �'F=.F�,��r� If Fe5 TYPE OF ASSEMBLY ❑ Reduced Pressure Principle � Pressure Vacuum Breaker � Double Check � Atmospheric Vacuum Breaker Manufacturer. � Serial Number: ��l q�� Model Number: ��C. Size: ��� Reduced Pressure Principle Assembly/Double Check Valve Assembiy Pressure Vacuum Breaker 1st Check 2"d Check Relief Valve Air inlet Check Valve Initial Test DC—Closed Tight � Closed Tight � Opened At: Opened AL RP- psid psid psid Leaked psid Leaked Did nok open Leaked Repair Re(rairsl�ater�als Us�: DG Closed Tight Closed Tight Open At: Open At: Test Aker Repair RP- �sid psid sid p psid �,� � � ,�I �" �,g; �b "� -�� Pass Fail ❑ 1 /� /� �/�� � Certified Tester: Q�tf� �Contractor Name: ��fQ. €. L<<�t J�rf-��1 /!'a""�`<<Gc� Tester#: L�O� �� ContractorAddress: �.� GU��.�.ft �JIJ'� ct,(tfS' �x 7�,i,��8 Signature: Contractor Phone� �7;L�� ' �a/�� Revised 10(12 Backflow Device Test Report Permit#: Date: BacRflow: 0 Reg O Not Reg O Lic exp O Residential Commercial 0 New Assembly xisting Assembly O Repair of Existing Assembly JobAddress:��� .J• 1�`�Q1 �� L.pQAD �I '� System Owner:�'V'�c rvi �C��'C� A.�sembly Location: {Y61r���p�1T� e pYy��v 0-'i— �Y� �j p.���J ��, THE SACKFLOVV PREVENTION ASSEMBLY LISTED BELOVV HAS BFEN TESTED AND MAINTAWFD AS REOUIREiJ BY TCF(1 REGULATIONS AND I�CERTIFIED TO�E OPERATING W'ITHIN/\CCF_PT�'�BL.E FAFIMETF_RS TYPE OF ASSEMBLY � Reduced Pressure Principle ❑ Pressure Vacuum Breaker � Double Check ❑ Atmospheric Vacuum Breaker Manufacturer: _�N,1 �`�+\Y�S Serial Number: ��1 ��� Model Number: ��� �� Size: o��� Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum Breaker 1st Check 2"d Check Relief Valve Air Inlet Check Valve Initial Test DC—Closed Tight •� Closed Tight a• O ned At: Opened At: RP- psid � psid psid Leaked psid Leaked Did noi ope� LeakE� Repalr ReDeir6/hAaterla4s Usevd�, DC-Closed Tight Closed Tight Open At: Open At: Test After Repair RP- �sld psid psid psid Pass f� Fail O Certified Tester: 5 Contractor Name: �� Tester#: �� � ��,��SS ( Contractor Address: o ���`. Signature: Contractor Phone:��]d�—oZ� ����� Revised 10/12 Backflow Device Test Report Permit#: Date: BacRflow: 0 Reg O Not Reg O Lic exp O Residential Commercial O New Assembly Existing Assembly O Repair of Existing Assembly Job Address: �� S• Y--[7�_�0.1 �� , l,E,vO_��, �,L System Owner:��dV� K.p���V . Rssembly Locatio�:: 1�(��d��j �.p)�y�� � � M��� dt__u THE BACKFLOUV PREVENTION ASSEMBLY LISTED BELOVV HAS BFEN TESTED AND MAINTAINFD.AS RE�UIRED BY iCEC1 REGULATIONS AN�I�,�'.EP,TIRF_D TO BE OPERATWG WITHIN ACCEPTABL,E PARAMETF_f2S TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker � Double Check ❑ Atmospheric Vacuum Breaker Manufacturer: ��� Serial Number: �0�.� O3 Model Number: D�1 M\ �.T Size: G�+� Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum Breaker 1st Check 2ntl Check Relief Valve Air Inlet CheCk Valve Initial Test DC—Closed Tight� Closed Tight �� Opened At: Opened At: RP- psid psid psid Leaked psid Leaked Did not open Leaked Repalr Rsoeirs/AAaterfals Us� DC-Closed Tight Closed Tight Open At: Open At: Test After Repair RP- �sid psid psid psid Pass 4Y Fail ❑ Certified Tester: C-L �7 Contractor Name:�� Tester#: Contractor Address: �������� ��� Signature: Contractor Phone: GI�� - �.a�—q �Q Revised 10/12