Attach_5_TE-4_-_Backflow_Prevention_Test_Report.pdf

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Attached to
Backflow Preventer Maintenance
Solicitation number
W911S8-19-R-0008
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Attachment 5 of solicitation W911S8-19-R-0008

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BACKFLOW PREVENTION ASSEMBLY

TEST REPORT

SEND COPY TO: Public Works, O&M (CCS) - ATTN: IMWE-LEW PWU, BOX 339500 MS 17, Fort Lewis, WA 98433-9500

Assembly Facility Name Lewis

Acct Number Meter # Test Report Due:

Service Address Bldg Schedule Code

Assembly Info

Equip Location MR in basement SN U32474

Control Number 1010-001 Containment Mfr Wilkins

Contact Name Ph Type DCVA

Map Page Phone 2 Size 6.00

Model 350A

Valve Status

Protection Type

Hazard Type FSS Haz. Level low

Line pressure at time of test: 63 REPORT OF TEST RESULTS

Approved BFP

Check Valve #1 Check Valve #2 Relief Valve PVB/SVB Shut Off Valves

Initial Test

Passed

Failed

Held at

PSID

Closed Tight

Leaked

Held at

Opened at

Did Not Open

Air Inlet Opened at

Did not Open Check Held at

PSID

Leaked

#1 #2

R E P A I R

CLEANED

REPLACED

Disc Spring Guide Seat

Hinge Pin Module

Disc Spring Guide Seat

Hinge Pin

Disc Spring Diaphragm Stem

O-Ring(s)

Air Inlet Disc Air lnlet Spring Check Disc Check Spring

Float

Diaphragm

REPAIR

OTHER

Other/Notes NEW

Final Test

PSID

Closed Tight

Opened at

Air Inlet PSID CK Valve PSID

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

Initial Test By

Certificate

Date

Gauge Num

Time In Time Out Company

Phone

Final Test By Certificate Date Gauge Num Company

Phone

Repair By

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