372 10th St IRR23-0011 - Back Flow Prevention Test Report I JOB COPY
f- City of Atlantic Beach—BACKFLOW PREVENTION ASSEMBLY TEST REPORT
902 Assisi Lane Jacksonville, Florida 32233 Phone: 904-247-5886
Name of Premises: / le4�!/t)etiLr
ree � .�-✓�-tid-, Account No:
ti
Service Address: -,:j1 Z t
1 0 Sri'ze-E-T
Mailing Address(If Different):
Contact Person: Phone Number:
Type of Service: n Process n Fire n Domestic V Irrigation Other:
Type of Assembly: 4P nom' Manufacturer: �',__,
Model: 1 Serial No: .J~ �' /44.0 624)/ 770 G' 6 7-- le,
Size:
/ 1 Location: Ze/'S'` .5,;-;c, D r''T '°rK`e`
Gauge Manuf: 111//J It ' Serial No: C37 /4206..`' Date Calibrated/Verified: //5-713
Check Valve#1 Check Valve#2 Relief Valve PVB or SVB
— ID'Closed tight — Closed tight
"0pened�at ❑Air inlet opened at PSI
R at PSI at 3.'t1 PSI 'O PSI I Did not open
❑ Leaked ❑ Leaked ❑ DidNot open — Check Valve Held at PSI
❑ Leaked
❑Cleaned only ❑ Cleaned Only ❑Cleaned Only ❑Cleaned Only
Replaced: Replaced: Replaced: Replaced:
❑ Rubber Kit ❑ Rubber Kit 0 Rubber Kit ['Rubber Kit
❑ CV Assembly ❑ CV Assembly 0 CV Assembly DCV Assembly
❑ Disc 0 Disc ❑ Disc ❑Disc
0 0-Rings 0 0-Rings ❑ 0-Rings ❑0-Rings
G. ❑ Seat ❑ Seat 0 Seat ❑Seat
Y ❑ Spring El Spring 0 Spring ❑Spring
❑ Stem/Guide ❑ Stem/Guide El Stem/Guide ❑Stem/Guide
❑ Retainer ❑ Retainer 0 Retainer ❑Retainer
❑ Lock Nuts ❑ Lock Nuts ❑ Lock Nuts ❑Lock Nuts
❑ Other,Describe ❑ Other,Describe 0 Other,DescribelD ❑Other,Describe
Closed tight at Closed tight.2
Opened at. :moi' PSI Air Inlet PSI
PSI 3 0 PSI Check Valve PSI
Remarks:
I certify that the data in this report is accurate. /
Tester Name (print) : ia✓+1 r".) �� �
"-/ Date: r( 3 43
Tester Signature: f TV__ /‘_.-----
, �� Phone:(7C �3� 1��/7
Affiliation: Feil Cert No.: Co 3--43— / 3Z7 ?
Tester Company: ,'4/( `fi2/t-,qa-�,c-- Address: PU1OSL 75�c9S G'���""p-//4i
// j,/ 3 2 e 5—
THIS ASSEMBLY 0 PASSED 0 FAILED
Email completed form to Ebrown@coab.us/jdsmith@coab.us