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Dec. 12. 2011— 9:47AM 1141 L. <br /> No, 4291---P: 5 <br /> • 24428 Greenways Avenue <br /> ANNUAL TEST FORM 51-442gg#0MMHG,AL.sm'Vri.•.Yp KWnT/NtC BACKFLOW PREVENTORS tax. 631-4sa-2425 <br /> Email; infa@cpandh,cclis <br /> CUSTOMERI, Z', �(" I\ 1 �1 )\ <br /> STREET ADDRESS ►r. +. 4 ►• flat , t.ati - . <br /> MAILING ADDRESS' 0 rb Ylb )M,1-\ • S -27 4__• <br /> NEW INSTALLATzgND EXISTINGN REPLACEMENT ❑ OLD ASSEMBLY S,N <br /> LOCATION OF ASSEMBLY1 `C <br /> TYPE OF ASSEMBLY' RPZ[J DCVO PVBD SVBE SIZE' 1 _ INSTALLATION DATE' <br /> MANUFACTURER' - MODEL' c'1 to C SERIAL #' x.)0131'1 <br /> RELIEF VALVE VALVA CH #z CHECK VALVE #1 CHECK VALVE ##2 pressure Split DOUBLE CHECK VALVE <br /> Vacuum Resistant <br /> Back Pressure In Direction of In Direction of BreakerVac'" '' In Direction of <br /> Test Flow Test Flow TestBreaker Flow Test <br /> Opened at ❑ Leaked <br /> 0 Leaked El Leaked Mr In(e4 opened at <br /> � #1 #2 <br /> LA' Lf sl 0 Closed Tight psi Leaked ULeaked <br /> p ❑ Closed TI ht <br /> 9 DlfFeren*lal Pressure ❑ Closed Tight Dlol Not ❑peri Closed Closed <br /> Did Not 0 Across check valve DIPferentlal Pressure <br /> Open LJ Across check valve Check Valve ❑ ❑ Tight ❑ Tight <br /> (Must Be % - psi Leaked ❑ <br /> 2 PSI or (Must Be At Least psi <br /> 3 PSI Higher Than held nt <br /> Greater) The Relief Valve) psi P51 psi <br /> PASSED El PASSED 'E PASSED EJ PASSED ❑ PASSED EI PASSED( PASSED❑r <br /> FAILED E] FAILED ❑ FAILED El FAILED ElFAILED [] FAILEDE FAILED[] <br /> _ <br /> CHECK ALL THAT APPLY <br /> ['Cleaned Linty Cleaned Only DCleaned Only ! ❑Cleaned Only ❑Cleaned Only, #1 #2 <br /> Replaced Replaced! Replaced' R,placed' Replaced' ❑Cleaned Cleaned <br /> Only Only <br /> Rubber Kit Rubber Kit— Rubber Kft,_ d <br /> Rubber Kit_ Rubber K1t— ReQlace ' <br /> Assembly_ Assembly_ Assembly_ Assembly_ Assembly_ Rubber Klt''Rubber kit—' <br /> DIS c_ Disc DISC Disc Disc, air In <br /> Diaphragm.. D-rings_ ❑-rings_ ❑--rings_ Disc, CV _ Assembly=AsseDbly <br /> Spring_ Spring_ Spring Spring, S ring, air DISC Disc_ <br /> d-sins_ Other Other Other Spring, <br /> — R-piing— ❑Sprng_ <br /> Other_ — 9 _ Spring— Spring_ <br /> — Other Either— Other <br /> — <br /> Describe Repairs i a. a - -.1 _+ .Q citi 1x\1 l V- <br /> °pened Qt Differential Pressure DIPPerentlal Pressure Alr Inlet sl Check RI <br /> Closed ti ht Across check valve Across check valve P psi <br /> Psi psi psi Check valve psi' Cheek *2 psi <br /> Opened shut oF•F #1❑ Opened shut off 420 Water Pressure Test Kit SN <br /> Remarks' <br /> — <br /> I hereby certify that this date Is accuradif and re lects the proper operation and maintenance of t e assembly, <br /> TESTER'S NAME (PRINT) G,' 0 A. - • CERT. # QInloa I <br /> TESTER'S SIGNATURE ,•.. ! r/_ ./&-r.s DATE i< 'll i 1 .TIME <br /> COMPANY C � <br />