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W O#: <br />Test of <br />BACKFLOW PREVENTER TEST REPORT <br />JOB ADDRESS (INCLUDE ADDRESS #, STREET NAME, & DIRECTIONAL), Apt/Unit # <br />S n6 _S � -, I,n_e� IV -- V Z..L, . MNl <br />BACKFLOW ASSEMBLY INFORMATION (All Fields are Required) <br />System Served: Manufacturer of Assembly:—L=' — �r Model # <br />if <br />Size of Assembly: Serial# <br />vo <br />e!"r <br />Location of Assembly: Floor # e Room it Date test was performed: <br />Reduced Pressure Principle Backflow Pre_venter (RP) —TEST RESULTS <br />Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential <br />Relief Valve <br />Closed Tight Yes Mo <br />Closed Tight ❑Yesallo <br />Closed Tight Q Yes ONo <br />Closed Tight Yes �No <br />Closed Tight1:1 Ye No <br />Initial Test <br />Check Valve 91 psid <br />Pressure Drop Across <br />Opened at psid <br />/ { <br />Closed Tight� =No <br />Check Valve #1 psid <br />Opened at t psid <br />Describe parts and <br />Check Valve #1 9' psid <br />repairs when needed <br />Final Test <br />Closed Tight _ Yes _No Closed Tight Yes No Closed Tight _ Yes _No <br />— — <br />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 TightaYes r--lNo Closed Tight r--1 Yes CZ:1Vo <br />Closed Tight 1:1Yes MN, <br />Initial Test <br />psid psid <br />Describe parts and <br />repairs when needed <br />Closed Tight _ es _No Closed Tight Yes o <br />Final Test <br />_ , <br />Closed Tight 0 Yes ONo <br />psid psid <br />Pressur <br />Initial Test <br />Describe parts and <br />repairs when needed <br />Final Test <br />e Vacuum Breaker Assembly (PVB) <br />Air Inlet Valve <br />or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS <br />Check Valve Shutoff #2 <br />Failed to OpeE=:3Ye ,No <br />Closed Tight Yes Mo <br />Pressure Drop Across <br />Closed Tight1:1 Ye No <br />Opened at psid <br />Check Valve 91 psid <br />/ { <br />Closed Tight� =No <br />Closed Tight �Ye10No <br />g <br />Opened at t psid <br />Pressure DropA r sss <br />Check Valve #1 9' psid <br />CERTIFICATION: I certify the foregoing information provided by me to be correct and that the tested device is functioning with the limits of the standards. <br />Name (Print): BIII NaatZ Signature: Date:State of of MN Certificate Number: <br />