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ASSE International RECEIVED
Reduced Pressure Principle Backflow Preventer(RP) MAY 1 � 2017
ASSE Standard#�1013 Field Test Report
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Owner of Property � ' $
Address y ����` ��-
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., ' {�te ' Zip Code
Occu arrt of Pro e �� ' "���� `
P P rtY(if different from own�r) _. ,�,;s,�,�.�..���. H--
Occupant Address �,;�_
City St�t�, Zip Code
Manufacturer of Assembly:,�i (k( h � 4 Model#: Q ?�J ��....
Size of Assembiy: � �' Serial#: y
Location of Assembly and Equipment or System Application: ' �
Test EquipmeR: l ''
Manufacturer:�i C�-�IUes-�' Model#: _$y S -S Se��#: b� � �- y�a
Calibration Date: 3-l5-'a.01 �-
Date test was perFormed: 5 �1 I� Time test was perfiormed: ��Cc.lM Static Line Pressure: "7� �
Check Valve#2 Shutoff vaNe#2 Checic Valve#1 P�Sure Differential
Relief Vaive
Leaking ( )
Initfal Test �aking ) Leaking ( ) Closed TigM (�
Closed Tight � Closed Tight � Pr+essu�s Drop Across Opened at_psid
, q .5 cn�vawe� sia .
u����� q ,°t -�
and repairs
when needed
Leakin9 ( )
Closed Ti ht
Final Teat Cj s�Tight ( ) Closed TigM ( ) P�'°�ure Drop Across Opened at_psid
Check Valve#1 sid
Certified Tester( rint) 1 ' Assembly Final
Address � v� Test Performance
.
Ciry�,�v�v�i�Gz State I�iV Zip �5 (p P�
Phone#: 5 - q -
�icense#: ? ce�t�ication# 3`�3$�o Fail �
Signature Date: �� � ?
Comments or Recommendations(conttnue to otner s�ae,ff neeaed):