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Dec, 12. 2017— 9:47AM — 1� �� No, 4291—P. 3 — <br /> 24428 Greenway Avenue <br /> ANNUAL TEST FORM 1- MN 5P 65a <br /> #OMMENCIAI <br /> *rn ? <br /> aar.wcti kii..ram: BACKFLOW PREVENTORS Fina:6�Ln spa dh.ec u <br /> CUSTOMER' ih ••I• .•Is. \ ! tot • <br /> STREET ADDRESS btc . 1.4 1 <br /> MAILING ADDRESS P(D. 1-1.1::). '-:r---T--)3:31„, <br /> NEV INSTALLATION❑ EXISTINGEO REPLACEMENT El OLD ASSEMBLY S.N. <br /> LOCATION OF ASSEMBLY: CAI 111 lir " '-'. A, : tY1 <br /> TYPE OF ASSEMBLY: ��(XR""PZ' DCVO PVBE SVBD SIZES �`, E <br /> INSTALLATION DAT <br /> MANUFACTURERS \IMODEL: knt -ZZ- SERIAL IS: I LLC <br /> RELIEF VALVE CHECVALVE K#� CHECK VALVE #1 CHECK VALVE #2 pressure Sp1ll DOUBLE CHECK VALVE <br /> Vacuum Resistant <br /> Back Pressure In Direction of In Direction of Breaker Vacuum En Direction of <br /> Test Flow Test Flow Test Breaker Flow Test <br /> Opened a 11 Leaked I=1Leaked El Leaked Air Inlet opened at #1 #2 <br /> s1 <br /> ElClosedTight El <br /> pqj ❑Leaked Leaked <br /> p ❑ Closed Tight Differential Pressure ❑ Closed Tight <br /> Did Not Across check valva Dld Not Open Closed Closed <br /> !]pen Differential Pressure Check Valve ❑ Li Tight ❑ Tight <br /> . Across check valve <br /> (Must Be <br /> psi Leaked <br /> 2 PSI Beor (Must Be At Least Psi <br /> 3 PSI Higher Than <br /> Greater) The Relief Valve) held at psi -psi psi <br /> PASSED PASSED f, PASSED El PASSED ❑ PASSED PASSED 0 PASSED❑ <br /> FAILED FAILED ❑ FAILED ❑ FAILED ❑ FAILED ❑ FAILED FAILED <br /> CHECK ALL THAT APPLY <br /> ❑Cleaned Only ❑Cleaned Only EICleaned Only ❑Cleaned Only ❑Cleaned Only #1 #a <br /> Replaced Replaced! Replaced( Replageit Replaced' ❑Cleaned ❑Cleaned <br /> Only Only <br /> Rubber Klt— Rubber Kit_ Rubber Kit_, Rubber Klt— Rubber Kit— Replaced' <br /> Assembly_ Assembly_ Assembly'. Assembly.. Assembly. Rubber Ki Rubber Kit— <br /> Disc_ Disc Disc Disc Disc, air In <br /> Assembly Assembly=Diaphragm_ D-rings_ D-rings ❑-rings_ Disc, CV D1sc Disc <br /> Spring_ Spring_ Spring. Spring Spring, air_ [primps D--rings: <br /> d-rings_ Either Other Other 0-ring Spring Spring_ <br /> Either Other Dither Other_ <br /> Describe Repairs' la'. k ''Z , ... Mika_ _ k MIM1121 <br /> Opened at Differential Pressure Differential Pressure Air Inletpsi Check #1 <br /> ❑Closed tight Across check valve Across check valve psi <br /> _psi psi psi Check valve psi Check #2 psi <br /> Opened shut off #10 Opened shut oFF #2111 Water Pressure Test Kit SN <br /> Remarks: <br /> I hereby Certify that this date Is accur4 and ref ects the proper operation and maintenance of the assembly,TESTER'S NAME (PRINT) � r4 r CERT, # to <br /> TESTER'S SIGNATURE S___.Q _ DATES 11. 11._ TIME <br /> COMPANY C�C:z <br />