Backflow Test Report - 320 10th Street001ALL UNITED
BACKFLOW PREVENTER
TEST REPORTCONTRACTING INC
5000 US Hwy 17 S Suite 18-132
Fleming lsland, FL 32003 32068 Phone:904-207-7707
Repairs/u n usual i nstal lation cond itions/replacement details:Part 5:
lstate information on this form is conect at the time and place of my inspection and that all equipment
tested at this time was lefr in operational condition upon completion of this insp€clion except as noted in part 5 above.
Thb fo,m coye,3 the mlnlmum requlrDments o, UF TREEO and AmryA Standard.
Name of premises
Attoil $,,ae"tt;tt
Owner or agent's name
HeAitkC t*aoS
3zo hr# g<aef nfu*#o po,#
Service address Mailing aOOrdss
s,4mL
welr s,L/e /4<4'
Location of device
Qo/- Yz< - ?to L
Contact phone number
Account number /
786ft - 167 7--7/t 3so q(Meter number
E Repair El Replacement fl New lnstaltation
E lnigation l-l Process/lsolation EI Potable
ls reclaimed water supplied ? aYes E No
Commercial test purpose
Commercial service type
El Annual
E Firel-I fire bypass
Residential test purpose E Annual EI Repair E Replacement
Residential service type Et Potabfe NniOation / ts reclaimed water supplied? l-l Yes E tto
Device type
RP
Manufacturer
nR.r
Sizetl
I
Model Number
Rf-w
Serial Number
fiffir&o
lnstallation date
ry'Zazo
Check valve #1 Check valve #2 Differential pressure
relief valve
aPrcssure vacuum
breaker
INITIAL
TEST
p Ctosed tight
M"i'
tr Closed tight
at Z,O ps.
fl Leaked
,Fge;lssiH,
E Did not open
g Air inlet opened at
_ pst
E Did not open
FINAL
TEST
EI Closed tight
at
-
psi
EI Closed tight
at _ psi
f-] Ooened at
lDs reouceo pressure ;3 Satisfactory
lnitial test oerformed bv/nluil< t<t,i//,|wts Company name nnl |trS1a,(BFDT certfficate numberioq -l ?-8 ?7 7 Test Datel2-ol- 2o
Repaired by Company name BFDT certificate number Repaired Date
Finaltest performed by Company name BFDT certificate number Test Date
ffp"""ed / Elfailed and supportive data is accurate.
/2- o/-Signature Date
PASS/FAIL C ERTIFICATION
I hereby certify the described above
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