HomeMy WebLinkAbout05-16-2022 RPZ Test ReportW O#:
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BACKFLOW PREVENTER TEST REPORT
JOB ADDRESS (INCLUDE ADDRESS #, STREET NAME, & DIRECTIONAL), Apt/Unit #
S n6 _S � -, I,n_e� IV -- V Z..L, . MNl
BACKFLOW ASSEMBLY INFORMATION (All Fields are Required)
System Served: Manufacturer of Assembly:—L=' — �r Model #
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Size of Assembly: Serial#
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Location of Assembly: Floor # e Room it Date test was performed:
Reduced Pressure Principle Backflow Pre_venter (RP) —TEST RESULTS
Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential
Relief Valve
Closed Tight Yes Mo
Closed Tight ❑Yesallo
Closed Tight Q Yes ONo
Closed Tight Yes �No
Closed Tight1:1 Ye No
Initial Test
Check Valve 91 psid
Pressure Drop Across
Opened at psid
/ {
Closed Tight� =No
Check Valve #1 psid
Opened at t psid
Describe parts and
Check Valve #1 9' psid
repairs when needed
Final Test
Closed Tight _ Yes _No Closed Tight Yes No Closed Tight _ Yes _No
— —
Pressure Drop Across Opened at _psid
Check Valve #1 psid
Double Check Backflow Prevention Assembly (DC) — TEST RESULTS
Check Valve #1 Check Valve #2 Shutoff Valve #2
Closed TightaYes r--lNo Closed Tight r--1 Yes CZ:1Vo
Closed Tight 1:1Yes MN,
Initial Test
psid psid
Describe parts and
repairs when needed
Closed Tight _ es _No Closed Tight Yes o
Final Test
_ ,
Closed Tight 0 Yes ONo
psid psid
Pressur
Initial Test
Describe parts and
repairs when needed
Final Test
e Vacuum Breaker Assembly (PVB)
Air Inlet Valve
or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS
Check Valve Shutoff #2
Failed to OpeE=:3Ye ,No
Closed Tight Yes Mo
Pressure Drop Across
Closed Tight1:1 Ye No
Opened at psid
Check Valve 91 psid
/ {
Closed Tight� =No
Closed Tight �Ye10No
g
Opened at t psid
Pressure DropA r sss
Check Valve #1 9' psid
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.
Name (Print): BIII NaatZ Signature: Date:State of of MN Certificate Number: