Laserfiche WebLink
HYDROCORP. <br />THE SAFE WATER AUTHORITY.. <br />800.690.6651 <br />Email completed test forms to:testforms@hydrocorpinc.com <br />or fax to: (248) 786-1789 <br />Backflow Prevention Assembly Test & Maintenance Form <br />Owner of Property ORONO MIODLE SCH Return Form By: <br />Mailing Address Test Date 8-28-2024 <br />(CITY)(ST)(ZIP)RP-ASSE #1013 ☐RPDA-ASSE #1047 <br />Contact Person DC-ASSE #1015 ☐DCDA-ASSE #1048 <br />Assebly Adress go0 N. old Corstal Bar <br />Rd. OroNu, MN 55356(CITY) (ST) (ZP) <br />Exact Location BrCLERROom <br />PVB-ASSE #1020 ☐SRVB-ASSE #1058 <br />Permit Number <br />Make APOLLо Model No. BPLF4A0 <br />BrilERt Chillo Feed Stre 14 Serial No. 67871C <br />Line PSI <br />5.5 <br />Check Valve No. 1 <br />Initial Test Closed Tight Ε Z Opened at <br />PASS <br />FAIL <br />Leaked 미 <br />86 PSID <br />Reduced Pressure Backflow Preventer <br />Double Check Valve Assembly <br />Check Valve No. 2 <br />Closed Tight <br />Leaked <br />20 PSID <br />Relief Valve <br />2. PSID <br />Did Not Open☐ <br />Pressure Vacuum Breaker <br />Spill Resistant Vacuum Breaker <br />Check Valve <br />Closed Tight <br />Air Inlet <br />Opened at <br />_ PSID <br />Did Not Open <br />Leaked Π <br />PSID <br />Repairs <br />Final Test <br />PASS <br />Closed Tight Closed Tight ☐ Opened at <br />PSID PSID <br />Condition of No. 2 Shutoff Valve: Closed Tight ☐ <br />_ PSID <br />Leaked <br />Notes: <br />Closed Tight <br />_ PSID <br />Water Service Restored <br />Opened at <br />_ PSID <br />Yes No <br />Certification: On this date, the above device was tested per applicable codes and the required performance standards. <br />Test Type <br />Tester Name <br />Gauge Ser. No.11161497 <br />Bret Hepoa <br />Taetar Signatine: Bae <br />Contact Signature: <br />Taeting Fim A( CIY PLUMBING <br />Tester Certification No.AOSE 33650/64.39701 <br />Da 8-26-2ezy <br />Date: <br />BPA Test Form Revised 05-2015 | HydroCorp