374 4TH ST 1RR22-0014 BACKFLOW JOB COPY
'"' City of Atlantic Beach—BACKFLOW PREVENTION ASSEMBLY TEST REPORT
\far 902 Assisi Lane Jacksonville, Florida 32233 Phone: 904-247-5886
Name of Premises: /("/<, 94714 Z ,1 Account No:
Service Address: )7/ std ' ST/. ./%` ,4-/' 7/
Mailing Address(If Different):re �
Contact Person: /' 2i Till' 3 i Phone Number: ��97�.J-[�7 9
Type of Service: n Process n Fire n Domestic krrigation n Other:
Type of Assembly: ,,/ Manufacturer: i11/feo
Model: !o.0 Serial No:/.01/g/V4 ''//
Size: Location: k-5/ ji
Gauge Manuf: j��/,`�J- �,r.$7 Serial No: /i2O/c7z,/67 Date Calibrated/Verified: /C9�7V.Z3
Check Valve#1 Check Valve#2 Relief Valve PVB or SVB
Fog Closed tight , g Closed ti ht ❑ Opened at [11 Air inlet opened at PSI
7 at 7, y PSI at .0 PSI 7,A PSI ❑Did not open
El Leaked ❑ Leaked Li Did Not open
CI Check Valve Held at__
c 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 El CV Assembly ❑CV Assembly
i 0 Disc 0 Disc ❑ Disc ❑Disc
•s 0 0-Rings El 0-Rings ❑ 0-Rings DO-Rings
�
. ❑ Seat 1:1 Seat El Seat ❑Seat
El Spring ❑ Spring ❑ Spring ❑Spring
❑ Stem/Guide ❑ Stem/Guide ❑ Stem/Guide ❑Stem/Guide
❑ Retainer ❑ Retainer 0 Retainer ❑Retainer
❑ Lock Nuts ❑ Lock Nuts ❑ Lock Nuts ❑Lock Nuts
❑ Other,Describe ❑ Other,Describe ❑ Other,Describe ❑Other,Describe
Closed tight at1
Closed tight at Opened at PSI Air Inlet PSI
PSI PSI Check Valve PSI
Remarks:
I certify that the data in this report is accurate.
Tester Name(print) : /eC9/f "2_7— --/.4!7 Date: Z/1-/.7 .A3
Tester Signature: /(" !� Phone: 5U V'frit/ 3'$155
Affiliation: l‘T,-/ // T. :-z -s, ..mac Cert No.: /f 1-7/4.e?
Tester Company: /g-17.e-,;, /4/45 ----"h c- Address: 42 /Sox- SO/IS
THIS ASSEMBLY $PASSED El FAILED
Email completed form to Ebrown@coab.us/jdsmith@coab.us