HomeMy WebLinkAboutVacuum Breaker American Society of Sanitary Engineering
Pressure Vacuum Breaker Assembly (PVB)
ASSE Standard#1020.Eield Test Report
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Owner of Property
Address LI 95 0 p t vl ry'
r City OC-OniLI State Y\f\' Zip Code 5-32-3
Occupant of Property(if different from owner)
Occupant Address
r City State Zip Code
t
0 Manufacturer of Device: c M del#: 6S
Size of Device: 1" Serial#: \ f\ 'I V 14)7 c
Location of Assembly and Equipment or System Application: S,og- c1C tie vA -, ei,r•cM Q► 1
Test Equipment: _
Manufacturer: f Q I�� Model#: --Luc o - /�- Serial #: O'1 Mit
Calibration Date: ET I
y
Date test was performed: ;, Time test was performed: 1 .O 3 Static Line Pressure:
7
Air Inlet Valve Check Valve Shut Off#2
Leaking ( )
Failed to Open Closed Tight ( ) Leaking ( )
I Initial Test
Opened at psid Pressure DropAcross
Closed Tight ( )
li, Check Valve#1 psid
Describe parts and
repairs when needed
Leaking ( ) j
Opened atZ .0psid Closed Tight l S— Leaking ( )
Final Test
Pressure Drop rossClosed Tighe
Check Valve#1 . psid `�
Certified Tester(print) ,.X..rtm_yZ Assembly Final Test
Addresx l6I6 t -4\e . Performance
City ' c:-0r. u,1 , State MN Zip ss-3-3l
Phone#: L t--L L Pas
License#: fGU-1'tbo) Certification# psse- -2-$OLIO Fail
Signature 1,.1 Date: ()S /2.1114-
Comments or Recommendations (continue to other side,if needed):
Cross-Connection Control Professional Qualcations Standard 77
ASSE Series 5000-2009