310 Plaza RES23-0113 -BACKFLOW PREVENTION ASSEMBLY TEST REPORTCity of Atlantic Beach—BACKFLOW PREVENTION ASSEMBLY TEST REPORT
902 Assisi Lane Jacksonville, Florida 32233 Phone: 904-(2)'47-5886
Name of PreS - b
mises• Soh Account No:
service Address:
11
Mailing Address (If Different):
Contact Person:
Phone Number:
Type of Service: Process Fire F-1Domestic Irrigation r-1other;
Type of Assembly; Manufacturer: '� n
Model: 2 Serial No: v
Size• Location:` / e �'U
Gauge Manuf: - (Srial No: /;Z !4q Date Calibrated/Verified:
Check Valve #1 Check Valve fit Relief Value PVB or SVS
[� Closed tight jFJ Closed tight ❑ Opened at ❑Air inlet opened at PSI
at PSI (- at 7,.,Z PSI E] Did not open
❑Check Valve Held at PSI
>; ❑ Leaked ❑ Leaked ❑ Did Not open ❑Leaked
Closed tight at Closed tight at Opened at:s Psl Air Inlet PSI
WPSI - /PSI — LCheck Valve PSI
Remarks: 1 F -Eh �K �reSSUr� D 4-j_ u- - '`-
I certify that the data in this report is accurate. /
Tester Name (print) : -7-- Date: l - Z2 _'9 3
Tester Signature: _ , Phone:c10_ ✓ �Sf
Affiliation: _!' Cert No.: �`T/l':�J
Tester Company: Address:
�. �r' ,Jr�� —� �� Address:
THIS ASSEMBLY �RASSED ❑ FAILED
Email completed form to Ebrown@coab.us/jdsmith@coab.us
❑ Cleaned only
❑ Cleaned Only
❑ Cleaned only
❑ Cleaned Only
Replaced:
Replaced:
Replaced:
Replaced:
❑ Rubber Kit
❑ Rubber Kit
❑ Rubber Kit
❑ Rubber Kit
❑ CV Assembly
❑ CV Assembly
❑ CV Assembly
❑ CV Assembly
v,
❑ Disc
Q Disc
❑ Disc
❑Dist
'i.
�
fl
O -Rin
-Rings
00 -Rings
❑ Seat
❑Seat
C] Seat
❑Seat
❑ Spring
Q Spring
❑ Spring
05pring
❑ Stem/Guide
❑Stem/Guide
❑ Stem/Guide
❑Stem/Guide
❑ Retainer
❑ Retainer
❑ Retainer
❑Retainer
❑ Lock Nuts
O Lock Nuts
❑ tock Nuts
QLock Nuts
❑ Other, Describe
Q Other, Describe
❑ Other, Describe
L70ther, Describe
Closed tight at Closed tight at Opened at:s Psl Air Inlet PSI
WPSI - /PSI — LCheck Valve PSI
Remarks: 1 F -Eh �K �reSSUr� D 4-j_ u- - '`-
I certify that the data in this report is accurate. /
Tester Name (print) : -7-- Date: l - Z2 _'9 3
Tester Signature: _ , Phone:c10_ ✓ �Sf
Affiliation: _!' Cert No.: �`T/l':�J
Tester Company: Address:
�. �r' ,Jr�� —� �� Address:
THIS ASSEMBLY �RASSED ❑ FAILED
Email completed form to Ebrown@coab.us/jdsmith@coab.us