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B & D PLUMBING, HEATING & Air Conditioning <br />4145 MacKenzie Court NE ANNUAL TEST <br />St. Michael, MN 55376 BACKFLOW PREVENTORS <br />Phone: 763-497-2290 <br />Fax: 763-497-4263 <br />CUSTOMER ��J S � �'� 7 / <br />STREET ADDRESS �Z S OZ -6 G `Ys ��G 3��' 2�/tfl LOA/;' L.fN« a7,,J , S's- -7s G <br />MAILING ADDRESS <br />PROPERTY OWNER <br />STREET ADDRESS <br />MAILING ADDRESS <br />LOCATION OF ASSEMBLY l��CIC of �/©SSC �T�2!"-Cfli6 <br />TYPE OF ASSEMBLY: RPZ DCV SIZE: / <br />MANUFACTURER:WCL/� 5 MODEL: 720 f} SERIAL#: ! yyl7oq <br />NOTE: ALL REPAIRS SHALL BE COMPELTED WITHIN TEN (10) DAYS. <br />REMARKS: <br />I HEARBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND <br />MAINTENANCE OF THE ASSEMBLY. <br />TESTER'S NAME (PRINT) Tho . -i3T062575 <br />TESTER'S SIGNATURE---------- DATE <br />CHECK VALVE #2 <br />CHECK VALVE #2 <br />PRESSURE <br />CHECK VALVE #1 <br />RELIEF VALVE <br />TEST #1 <br />TEST #2 <br />VACUUM <br />BACK PRESSURE <br />CONFIRMATION <br />BREAKER <br />Air inlet opened at <br />leaked <br />opened at: psi <br />leaked <br />leaked <br />3, a psi <br />did not open <br />p <br />closed tight <br />did not open <br />closed tight <br />closed tight <br />Differential pressure <br />flAU$T ®PEN AT <br />Differential pressure <br />p <br />Differential pressure <br />p <br />check valve: <br />across check valve <br />Across check valve <br />Across check valve <br />psi <br />ALAST 2 PSI. <br />psi <br />psi <br />leaked <br />must be 3 psi <br />Must be at least <br />held at 9 psi <br />above relief valve <br />1 psi <br />Cleaned only <br />Cleaned only <br />Cleaned only <br />Cleaned only <br />Cleaned only <br />Replaced: <br />Replaced: <br />Replaced: <br />Replaced: <br />Replaced: <br />rubber kit <br />rubber kit <br />rubber kit <br />rubber kit <br />rubber kit <br />CV assembly <br />RV assembly <br />CV assembly <br />CV assembly <br />CV assembly <br />or disc <br />or disc <br />or disc <br />or disc <br />disc, air in <br />o -rings <br />diaphragm(s) <br />o -rings <br />o -rings <br />disc, CV <br />seat <br />seat <br />seat <br />seat <br />spring, air <br />spring <br />spring <br />spring <br />spring <br />spring, CV <br />stem/guide <br />guide <br />stem/guide <br />stem/guide <br />retainer <br />retainer <br />o -rings <br />retainer <br />retainer <br />guide <br />lock nuts <br />other <br />lock nuts <br />lock nuts <br />o -ring <br />other <br />other <br />other <br />other <br />Differential pressure <br />Opened at <br />Differential pressure <br />Differential pressure <br />Air inlet psi <br />across check valve <br />psi <br />across check valve <br />across check valve <br />Check valve <br />psi <br />psi_psipsi <br />NOTE: ALL REPAIRS SHALL BE COMPELTED WITHIN TEN (10) DAYS. <br />REMARKS: <br />I HEARBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND <br />MAINTENANCE OF THE ASSEMBLY. <br />TESTER'S NAME (PRINT) Tho . -i3T062575 <br />TESTER'S SIGNATURE---------- DATE <br />