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Backflow Test
Date: ,2.z -/ `f �+ :i;� /,, �s �Lg�. ��� � - �(� CUS70MER INFORMATION Customer Name: �"c="-rC��,.ScX� BillingAddress: /D/ Lr �-�+��c�-� ,�-+Uc� GR���sL.,.�,J y���Z- DeviceServiceAddress:./D/L C�M'Z-���-���� C+4-����—�"���r7 `/Lo3� Device Physical Location: 13A-s�ri��r.JT /� '�[J/+Jp �j�3JLJC/-fj4;1J/Gp»� �i�L'W� 7ype of Service �.Fireline �Industrial OCommercial �1Domestic �Irrigation Bac!<flow installed as �Isolafion I�Containment Serial: G3/ 3350 Size: =z i.ucrt MFG: i=c-sf3�-� Model #: ��s ��,CF��I�OW IR1ST,�LI� �YAiIJS Backflow Device Was:�New Installation �Existing �Replaced (Enter New Serial)_ � `���i RESU�.`�� �ve�sve Relief Ualve Opened @ ��`� PSID Air Inlet opened @ PSID ❑ Relief Valve Did Not Open � Air Inlet Did not Open Check Valve #2 �Closed Tight ❑Leaked Check Valve Neld Tight @ PSI� Check Valve #1 Held Tight @ �%� � Check Valve Leaked ❑ Leaked �11R G�P Pipe Supply Diameter Size MeasurementAbove OverFlow Rim Z Inches �Inches DC Check balve #1 Held Tight @ Check Valve #2 Held Tight @ PSID �Check#1 Leaked . PSID ❑ Check #2 Leaked ' AV� �ackglow%sf Resulks �lE�as� 9Fail CheckValve Opened Fully �Yes ❑No GCafUINI�fU-f� ( Including IUl�inpenance i�'er�ormeq ) /%OcJ�JTZ.�C� /foZ�zc�c.�TigL-- pr2pr�. � z-'�� o �-.Z�� �-,z c=� z.,.�� ies�er Inforrnafiion / �� � . i �� i Iester Name: ArchonSafe UserName: 3�`3E� This form is just a worksheef and may not be submitted to the Water Utility. All information must be submitted to ArchonSafe.com or via the ArchonSafe Mobile App Re�ul�s ��1� !'� . �jr,,�. i'1r,, {�r1j"/'�'I�, � . � 1 ; ', � �. . � _