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RECEIVED <br /> SEP 3 0 2016 <br /> BACKFLOW PREVENTER TEST REPORT C�N OF ORONO <br /> - :�� G�� � � � I �- �� <br /> l 1 ,� .' C� , r71 <l � <br /> �l C/�� G� ��"��t l I , ( .I l:`l� � � / � L 1�1 <br /> 10B ADDRESS(INCLUDE ADDRE55#,STREET NAME,&DIRECTIONAL),Apt/Unit# <br /> -' `_/. / ��_- � <br /> XJ�/ � / /�� yI , / / ��, -�cl j <br /> � � "y V V `/�U r[,�I��`C !�L "V G.;1 .:-1 L�1 /C�.-� � �� � V,� .. � . ( <br /> BACKFLOW ASSEMBLY INFORMATION (All Fields are Required) <br /> ,-, r _ �, �,, �__ <br /> System Served: �-����,� ;i�>c„"t' l:.�` � 9���'✓Manufacturer ofAssembly: �. -�.-< 1 �� ��' Model# ��� ��; � <br /> Size of Assembly: / ✓ Serial# �<T�� "� C� <br /> , � �� ��. <br /> Location of Assembly: Floor#1 L'��''l r�' Room# /1 �-� = �� Date test was performed:�_� � . <br /> � <br /> Reduced Pressure Principle Backflow Preventer(RP)—TEST RESULTS <br /> Check Valve#2 Shutoff Valve#2 Check Valve#1 Pressure Differential <br /> Relief Valve <br /> Closed Tight ❑Yesallo Closed Tight Q Yes IINo Closed Tight �Yes QVo <br /> Initial Test Pressure Drop Across Opened at psid <br /> Check Valve#1 psid <br /> Describe parts and <br /> repairs when needed <br /> Closed Tight �Yes_No Closed Tight ,�Yes_No Closed Tight �Yes_No l <br /> Final Test Pressure Drop Across Opened at � �' psid <br /> Check Valve#1 ���i� psid <br /> Double Check Backflow Prevention Assembly(DC)—TEST RESULTS <br /> Check Valve#1 Check Valve#2 Shutoff Valve#2 <br /> Closed Tight ales DIVo Closed Tight �Yes�Vo Closed Tight�Yes�No <br /> Initial Test <br /> psid psid <br /> Describe parts and <br /> repairs when needed <br /> Closed Tight _ es_ o Closed Tight _Yes_ o Closed Tight 0 Yes�No <br /> Pinal Test <br /> psid psid <br /> Pressure Vacuum Breaker Assembly(PVB)or Spiil Resistant Vacuum Breaker(SRVB)—TEST RESULTS <br /> Air Inlet Valve Check Valve Shutoff tf2 <br /> Failed to Ope _ e _No Ciosed Tight Yes�lo Closed Tight Ye No <br /> Initial Test Pressure Drop Across <br /> Opened at psid Check Valve#1 psid <br /> Describe parts and <br /> repairs when needed <br /> Closed Tight Yes_No <br /> Final Test Opened at psid Pressure Drop Across Closed Tight _Yes_No <br /> Check Valve#1 psid <br /> CERTIFICATION:I certify the foregoing information provided by me to be correct and that the tested device is functioning with the limits of the standards. <br /> ��,- j � , , _..._----��-'- �"�._ - �C�'n <br /> Name(Print):�`;,� � ��✓ Signature: /,-' �- Date:� <br /> a /� <br /> State of MN Certificate Number: G� ��7 �l C�"'�l..1 ��. <br /> ( <br />