HomeMy WebLinkAboutBACKFLOW REPORT - NATIONALDate: 7 . Z —/ % Time: .Z
Customer Name: LLET�cwL--2
Billing Address: /D/ Lr 2+4-7z411 cT
Device Service Address: ,LD/ LE� C
Device Physical Location: 13As�ri��fti
Type of Service ❑.Fireline ®Industrial
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❑commercial DomeStlC ❑Irrigation
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Baclflow installed as ]�ISOlatlen ®Containment
Serial: 33.50 Size: oZ j.yct* MFG: i=crt3cc-) Model #:
BA,CKFLOW INSTALL STATUS
Backflow Device Was: []New Installation oNExisting ❑ Replaced (Enter New Serial)
TEST
Relief Valve Opened @ �I `/ PSID
❑ Relief Valve Did Not Open
Check Valve #2 CsdTight ❑Leaked
Check Valve #1 Held Tight @
[]Leaked
AIR GAP
Pipe Supply Diameter Size
Measurement Above Overflow Rim
IT3 .�r
UTIMP& "I
Air Inlet opened @ PSID
❑ Air Inlet Did not Open
Check Valve Held Tight @ PSID
[I Check Valve Leaked
DC
Check Valve #1 Held Tight @ PSID
2. Inches ❑ Check #1 Leaked
=Inches Check Valve #2 Held Tight @ PSID
❑ Check #2 Leaked
f3acttflow lest Results Pass ❑Fail
COMMENTS (Including Maintenance Performed )
Tester Information /
Tester Name:
ArchonSafe
Results
This form is just a worksheet and may not be submitted to the Water Utility.
All information must be submitted to ArchonSafe.com or via the ArchonSafe Mobile App