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Assembly Serial #:—
Test Date/Time:
Gauge Serial #:
District Required Info:
Tester Certification #:
Date Certification Expires:
Assembly Test Results: ` PASS FAIL
Backtlow Prevention Device Test & Maintenance Report
c Water DistricUAulhority: Account Contact Person
Contact Phone:
c Facility Name:
u Service Address: - 4S0 _Z6fyblasl )&,&Y
a Mailing Address: _
C Owner ❑ Manager ❑ Contractor L 1 Other — Contact Person:
V
M Company Name/title: — _ Contact Phone.
C
Meiling Address: — — —
Make: . N.. - --- -- Model:-----,- --- Size: _
Type: ❑ RPZ ❑ DC Li PVB C Slits Cl Air Gap D AVB Ll Other Device _
2• Date Installed: Location on Property: �,,,_ i :.t - .
3 � Replacement Device Orientation Service Protection
previous device serial rr Inlet' Cutlet: . 7 Domestic . I Containment
JE
verwal Up Fire I Isolators
i_j Vertical Down irrigation 1 Containmenl by Isolation
EK New Instellallon -1 --
Horizontal Olnor'"
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PSI:
Initial Test Results:
Repaired:
Cleaned
Re -test Results
Ti htness Differential
Line
c16u1 Cksa .:RV
Gkst k::? RV
n
Tightness Differential
Check Valve If
j Leah
Ck#1
" 'k
Ty"t
RPZ. DC. PVB SVe
D Tighl
_ chsc � spirtry: seal other
Check Valve #2
[1, Leak
Ck#2
LeaK
CI RPZ. DC
L I Tight
- disc spring -1 Seat Utter
T, t
C Relief Valve
RV
N Py, RPZ
- D,a m ra , seal o!hci
Repaired: Cleaned
`c Buffer
M RPZ
Art Inlet Art Inlei
Airinlef
fla Air Inlet
Cl Art inlet. PVB. SV8
= Shuloff Valve #1
Li Leak
C Ti I
;., t +- tonne! Inner
sOV xr C) en U n Arnva - O +n At De rture Dackpressurb exists? LI YES C7 NO
SOV x2 - Arnva er. At De arture Cause
F Shutoff Valve #2
1 Lcak �_ Tight
Assembly Concerns
Test Procedure
Comments:
(only r! applicable)
:J Incorrect installation
ADPA X ASSE
Incorrect Use
Turn off date _
Turn on date.
Turn off time.
Turn on erne'
$ Alarm CompanylFire Department Notified: " Fire suppression contractor certification # 8-04104
c Person Notified: __ _-e - _ _ _ Contacted by
_
z Turn off dateltime: _ Turn on dateltime:
Y Test Kit Make: _ Mid- West_ - _-__ Model: 845 ___ _ last Calibration Date: _ --
I ^weby ternry dwr the ,spn �• ,. r ; -rs ,s0V Of and SOV •.n ,raw- tKa, retwrwd ro the P06&CIn m f1ri they Kere 5rund and that Ire last rest lvew d "e acror" W
the reao are mre and acarare to the best or my atKmy
the prorea,m ,- . ..::,,red by Me were+- Damp.-! Aaffili shswn All") and rrosr w
(please print) AdS Back(law (pie print)
d Testing Company. Testing L L C Phone 970-W-3090 Customer Name' - _ — Phone:
F• (please pnnt))
Tester Name: � Tester Signature _ _ - - - Customer Signature: _ —
-
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety.