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—Dec, 12. 2017— 9:47AM — — b�� No. 4291—P. 4 <br /> 24428 Greenway Avenue. <br /> NNUAL TEST FORS Poi 65 4 4-29.86S <br /> SCOMINIII0M1,.n,�u�vn Ftk.�7'i4u <br /> BACKFLOW PREVENTORS Fax:. <br /> 651-464-2425 <br /> ab.co'i; <br /> CUSTOMER!. m 41i _ '-L \ `. . I , •1 <br /> STREET ADDRESS N 1c �k' 1,VV (e=0,1)) LI <br /> MAILING ADDRESS' Q 'r't�Y1Qj �o <br /> NEW INSTALLATION[] EXISTING' REPLACEMENT ❑ OLD ASSEMBLY, S.N. <br /> L❑CATI❑N OF ASSEMBLY' T+. "� " c .....!,-A iii, <br /> x. <br /> TYPE OF ASSEMBLY! RPZ] DCVO PVC] SVB❑ SIZE' a INSTALLATI❑N DATE! <br /> MANUFACTURER' MODEL'C I•ll 9-&—r SERIAL #a. t)V-t <br /> RELIEF VALVE CHECK CHECK VALVE #1 CHECK VALVE #E spill DOUBLE CHECK VALVE <br /> VALVE #'c Pressure Resistant <br /> Back Pressure In Direction of In Direction of Vacuum <br /> Vacuum In Direction of <br /> Test Flow Test Flow Test Breaker Flow Test <br /> Opened at n Leaked <br /> 0 Leaked 0 Leaked Aft- Inlet opened a± ill #2 <br /> Psi n Closed Tight L� psi ❑Leaked ❑Leaked <br /> ❑ Closed Tight DIFFerentlpl Pressure ❑ Closed Tight <br /> Did Not ❑ Across check valve Did Not ❑pen Closed Closed <br /> Open nlFferentlnl Pressure Check Valve 111 ❑ Tight ❑ Tight <br /> Across check valve <br /> (Must Be psi Leaked ❑ <br /> 2 PSI Be CMus't Be At Least - psi <br /> 3 PSI Higher Than held atpsi <br /> Greater) The Relief Valve) psi psi <br /> • <br /> PASSED 1:21PASSED j PASSED 14 PASSED ❑ PASSED ❑ PASSEbn PASSED❑ <br /> FAILED ❑ FAILED ❑ FAILED ❑ FAILED ❑ FAILED D FAILED❑ FAILEDf <br /> CHECK ALL THAT APPLY _ <br /> ❑Cleaned Only ❑Cleaned Only ❑Cleaned Only nCleaned Only ❑Cleaned Only #1 #2 <br /> Replaced $epi.aceri Replacet Replaced: Repllaced' ❑Cleaned Cleaned <br /> Only ❑ Only <br /> Rubber Kit Rubber Kit` Rubber Klt" Rubber KIt_ Rubber Klt— Replace' <br /> Assembly` Assembly. Assembly_ Assembly, Assembly Rubber Klt—Rubber Kit-- <br /> Disc Disc <br /> r Disc 'V- Disc_ Disc, air In <br /> AsseAsseDbl <br /> y_Diaphragm_ 0-rings O-rings_ 0—rings,.. Disc, CV Disc DlgcSpring _ Spring_ Spring_ Spring` Sprin�, air^ a-rIngs_ ❑-rings <br /> =O-rings, Other Other Other_ ring Spring_ Spring_Other_ Other Either Ether <br /> Describe Repairs'. i/ � i V <br /> Opened at Differential Pressure Differential Pressure Air Inlet sl Check #1 psi <br /> E]Closed tight Across check valve Across check valve P <br /> psi ,- psi psi Check valve psi Check #2 psi <br /> Opened shut off' *in Opened shut off #20 Water Pressure Test Kit SN <br /> Remarks' <br /> I hereby certify 'that 'this date is accura a and reflects the proper operation and maintenance of t e assembly. <br /> TESTER'S NAME (PRINT).. A`, V CERT, # T � _ <br /> TESTER'S SIGNATURE DATE_ 1 6�- II TIME <br /> COMPANY C.,- (:\ <br />