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RECEIVED <br /> SEP 3 0 2016 <br /> CITY OF ORONO <br /> BACKFLOW PREVENTER TEST REPORT <br /> C;,s�G,��, .� �,,, l 1 �, -,<<�_ 5�c`-. f-� ,=,' � `-� � ? S� G <br /> JOB ADDRE55(INCLUDE ADDRESS q,STREET NAME,&DIRECTIONAL),Apt/Unit# <br /> , ' � <br /> >h �SG� >GiU�� �,� > %!:: ���:�� �"'--� , t-� d��,iG!: � Sl 5`I <br /> BACKFLOW ASSEMBLY INFORMATION (All Fields are Required) <br /> , , , ,. ,;_. / <br /> System Served: �L��.S�� ����t��� � Manufacturer of Assembly:�:�.�� �L��� �� `� Model#�--f������/=i�/ �� <br /> � � <br /> � <br /> Size of Assembly: � � � Serial# <br /> C��7 / <br /> Location of Assembly: Floor# 1---� 1 ;'�� Room#/l � 1 ��� Date test was performed: l "//(�. <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 <br /> Final Test — — Pressure Drop Across Opened at_ psid <br /> Check Valve#1 psid <br /> Double Check Backflow Prevention Assembly(DC)—TEST RESULTS <br /> Check Valve#1 Check Valve#2 Shutoff Valve#2 <br /> Closed Tight aPes nNo Closed Tight 0 Yes�Vo <br /> Initial Test Closed Tight _Yes_No <br /> psid psid <br /> Describe parts and <br /> repairs when needed <br /> Closed Tight _ es_ o Closed Tight _Yes_ o <br /> Final Test Closed Tight 0 Yes�No <br /> psid psid <br /> Pressure Vacuum Breaker Assembly(PVB)or Spill Resistant Vacuum Breaker(SRVB)—TEST RESULTS <br /> Air Inlet Valve Check Valve Shutoff#2 <br /> Failed to Ope _ e _No Closed Tight Yes�lo <br /> Initial Test Pressure Drop Across Closed Tight Ye No <br /> Opened at psid Check Valve#1 psid <br /> Describe parts and <br /> repairs when needed <br /> ,� Closed Tight Yes_No � <br /> �� — Closed Tight �Yes No <br /> Final Test Opened at:�'�'y psid Pressure Drop Across — <br /> Check Valve#1 psid <br /> CERTIFICATION:I certify the foregoing infor,,m?ation provided by me to be correct and that the tested device is functioning with the limits of the standards. <br /> / /�� <br /> Name(Print): f�'l� � � ��� Signature: � C� L� Date:�� <br /> ' � ��� �5� � 7 ' <br /> State of MN Certificate Number: ��''�l �`' <br />