560 ELM WAY (2).PDF111111 lill 1111
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560 ELM ST
I
NAME OF- . hEMISES
SERVICE ADDRESS
ED M ONDS PUBL I C WORKS DE P A RTHENT
CITY OF
BACKFLOW DEVICI EST REPORT—
EET FILE
.5 /� �-
LOCATIO4 OF DEVICE 15-) y i
rnL4q!�ZL— —* I
2
DEVICE:
Serial No.
- Manufacturer flodel Sizdf
L INE PRESSURE AT TIME OF TEST— ;7 0 - . LBS.
PRESSURL.-DROP ACROSS FIRST CHECK VALVE
LBS.
CHECK, VALVE 1,10.
1
CHECK.VALVE NO.
2
DIFFEREfITIAL PRESSURE RELIEF VALVE --
INITIAL
1. LEAKED
0
1.' LEAKED
0
1. OPENED AT- LBS.
TEST
2. CLOSED.TIGHT
4-
2. CLOSEDTIGHT
REDUCED PRESSURE
2. DID HOT OPEN
CLEANED
0
CLEANED
0
CLEA-f-IED
REPLACED:
REPLACED:
REPLACED:,
I sc -------------
0
DI SC -------------
0
DISC. LIPPER ---------------------- C
R
SPRI i NG -----------
0
SpRpI(I ------------
FJ
D I SC. LO',-JER ---------------------- c
E
C, U I D -- ------------
1-1
(,(J I DE ------------
0
SPP I ING -------------------------- c
P
I Pi."l 4TAINER -----
El
PIN. RETAINER -----
0
DIAPHRAGM, LARGE
A
I I I i' ' C � T - - - - - - -
I ;E I
-
C, --------
E PIN
0
UPPER ------------------------- C
I
SEAT -� -------------
El
SEAT -------------
f-1
L 0 �-,E R -------------------------
R
D I A D H Rr'i G,1 --------
I]
DIAPHRAGM — -------
0
-DIAPHRAGM, SMALL
S
OTHER, DESCRIBE
0
OTHER, DESCRIBE --0
LIPPER -------------------------
LGIVT R ---------------
SPACER, LOWER
OTHER, DESCRIBE
OPENED AT LBS.
FINAL
TEST
CLOSED TIGH T ----- 0
CL OSED TIGHT -----
0
REDUCED KES.SURE
REMARKS�
THE ABOVE REPORT IS CERTIFIED,T0 BfEU�E,:
INITIAL. -TEST PERFORMED BY'",—, OF
RFPAIRF-0 BY
FINAL 'TEST PERFOR . NED BY OF
CERTTFICATE #: - SoO'7— -0 Otl'!Q
DATE_&---)V'f,7--i
DATE
DATE—