HomeMy WebLinkAbout800 Old Crystal Bay Road North - Inspection & Testing - Backflow Preventer TestHYDROCORP.
THE SAFE WATER AUTHORITY..
800.690.6651
Email completed test forms to:testforms@hydrocorpinc.com
or fax to: (248) 786-1789
Backflow Prevention Assembly Test & Maintenance Form
Owner of Property ORONO MIODLE SCH Return Form By:
Mailing Address Test Date 8-28-2024
(CITY)(ST)(ZIP)RP-ASSE #1013 ☐RPDA-ASSE #1047
Contact Person DC-ASSE #1015 ☐DCDA-ASSE #1048
Assebly Adress go0 N. old Corstal Bar
Rd. OroNu, MN 55356(CITY) (ST) (ZP)
Exact Location BrCLERROom
PVB-ASSE #1020 ☐SRVB-ASSE #1058
Permit Number
Make APOLLо Model No. BPLF4A0
BrilERt Chillo Feed Stre 14 Serial No. 67871C
Line PSI
5.5
Check Valve No. 1
Initial Test Closed Tight Ε Z Opened at
PASS
FAIL
Leaked 미
86 PSID
Reduced Pressure Backflow Preventer
Double Check Valve Assembly
Check Valve No. 2
Closed Tight
Leaked
20 PSID
Relief Valve
2. PSID
Did Not Open☐
Pressure Vacuum Breaker
Spill Resistant Vacuum Breaker
Check Valve
Closed Tight
Air Inlet
Opened at
_ PSID
Did Not Open
Leaked Π
PSID
Repairs
Final Test
PASS
Closed Tight Closed Tight ☐ Opened at
PSID PSID
Condition of No. 2 Shutoff Valve: Closed Tight ☐
_ PSID
Leaked
Notes:
Closed Tight
_ PSID
Water Service Restored
Opened at
_ PSID
Yes No
Certification: On this date, the above device was tested per applicable codes and the required performance standards.
Test Type
Tester Name
Gauge Ser. No.11161497
Bret Hepoa
Taetar Signatine: Bae
Contact Signature:
Taeting Fim A( CIY PLUMBING
Tester Certification No.AOSE 33650/64.39701
Da 8-26-2ezy
Date:
BPA Test Form Revised 05-2015 | HydroCorp