HomeMy WebLinkAbout2184 W 4th St - BuildingNAME OF PREMISES
SERVICE ADDRESS
LOCATION OF DEVICE. .1 t
ASSEMBLY
IS THIS AN APPROVED ASSEMBLY? YES la IS ASSEMBLY INSTALLED CORRECTLY? YES 0-NO
DATE OF INSTALLATION i 5UNKNOWN 0
Initial
Test
Repairs
Details
Final
Test
COMMENTS
X l /A
L/'4 77
Manufacturer
REDUCED PRESSURE PRINCIPLE ASSEMBLY
DOUBLE CHECK VALVE ASSEMBLY
CHECK VALVE #1
Leaked 0°
Held at I 3 psi
Cleaned
Replaced
AIR GAP INSPECTION
REQUIRED MINIMUM SEPARATION YES NO TYPE OF HAZARD /1 /4 A'
/A 1/ 2, :-r iE,
Closed Tight
Held at psi Held at psi Opened at psi
Date/Time Tester
Initial
Test 44 f% Sf
Repairs
Final
Test t tr •"r
Backflow Assembly Test Report
City of Port Angeles
Public Works and Utilities Department
Water/Wastewater Collection Division
/"Gc i 5 fG rN 0 WAi !e ��C `e,
Model Size Serial No
CHECK VALVE #2
Leaked
Closed Tight
Held at psi
Cleaned Cleaned
Replaced Replaced
Signature
RELIEF VALVE
3 psi Buffer YES NO
Did Not Open
Opened at psi
Line Pressure r ps
V fri,Y' we fi Q--
WHITE CUSTOMER COPY YELLOW PURVEYOR COPY PINK TESTER COPY
RP RPDA
DC DC DA
PVB Air Gap
SVB AVB
AIR INLET
Did Not Open
Opened at psi
Leaked Held at psi
REPAIRS
Cleaned
Replaced
Official Use Only
Assem.#
Received
PVB /SVB
CHECK VALVE
AIR INLET Opened at psi
CHECK VALVE Held at psi
BACK PRESSURE NO YES
Held Backpressure YES L:I" NO
#2 Shutoff Held YES CE'" NO
Relief Valve Exercised YES NO
Cert. Test Kit Passed Failed
o
E
1'