2021.12.02 - Atlantic Village Medical @ 1029 Atlantic Blvd - 1 in, M# 919QT, S# 75352 - sBACKFLOW ASSEMBLY TEST REPORT
City City
Device Type:
Mfg:Model No.
Check Valve # 1 Diff/Prsre ReliefValve Check Valve # 2 Prsre Vac Break
Opened at Air Inlet opened at
LBS.
Did not Open Did not Open
Closed Tight at
Remarks:
(Signature)
Customer Account Number:
Water Utility Co.
DCDA RPDA Service Type
Test Results
Initial By:
Repaired By:
Final by:
Commercial/Residential
Meter #
Location:
SCAN #
Size
Leaked Leaked
Customer Name:Customer Contact:
Service Address:Mailing Address:
State State
Closed Tight at
P.S.I
Final Check Valve # 1
P.S.I
Closed Tight at
P.S.I
Final Check Valve # 2
P.S.I
Relief Valve
LBS
P.S.I.
P.S.I.
Tech Name Affiliation Certification Test Date
I HEREBY CERTIFY THAT THIS DATA IS ACCURATE
Serial Number
Final Test Results
DC RP
Zip
Gauge
Company