HomeMy WebLinkAbout3711 Crabapple Pl - Engineering4 u3,"~'--~'.&-~& ~, om' a~,~,,,¢ Official Use Only
Received
Backflow Assembly Test Repo~
g City of Po~ Angeles
z~e~~'~ Public Works and Utilities Department
Water/Wastewater Collection Division
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NAME OF PREMISES: C- ' /'''~
SERVICE ADDRESS: fi /' / } ~' "' '; ?5 ? '" ~''~ ~ -~./'); A/~-
Manufacturer Model Size Serial No.
IS THIS AN APPROVED ASSEMBLY? ~S ~O ~ 1S ASSEMBLY INSTALLED CORRECTLY'? YES ~'No
DATE OF INSTALLATION ' ~'% ,/~?~ UNKNO~
REDUCED PRESSURE PRINCIPLE ASSEMBLY Re ~ RPDA
DC ~' DCDA
PVB ~ Ah' Gap
DOUBLE CHECKVALVE ASSEMBLY SVB ~ AVB
Initial Leaked ~ Leaked ~ Did Not Open ~ AIR INLET
Closed Tight ~ Did Not Open
Held at ~ . ~ psi Opened at ~ psi
Repairs Cleaned ~ Cleaned ~ Clean~ ~ CHECK VALVE
Leaked ~ Held at psi
Replaced ~ Replaced ~ Replaced
Cleaned
Derails
Replaced
3 psi ~ufl~r YES ~ NO ~
~ ~ CHECK VALVE Held at ~_ psi
Test Held al - ) pst Held at~ * ~psi Opened at psi BACK PRESSURE NO
REQUIRED MINIMUM SEPA~TION: YES ~ NO ~ TYPE OF HAZARD
~2 Shutoff Held YES ~. NO
Relief Valve Exercised YES ~ NO
Ddt&Time Tesl~ Si~amre Cen ~ Test Kil Pass~ Failed
Repairs
WHITE - CUSTOMER COPY YELLOW - PURVEYOR COPY PINK - TESTER COPY