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CITY OF KENNEWICK BACKFLOW PREVENTION ASSEMBLY TEST REPORT CONTACT NAME / COMPANY: ADDRESS / PHONE ASSEMBLY LOCATION: BACKFLOW HAZARD: MANUFACTURER: MODEL: SIZE: REPLACEMENT - OLD SERIAL NO. SERIAL No: NEW ORIENTATION AT TIME OF TEST: HORIZONTAL VERTICAL UP EXISTING VERTICAL DOWN INITIAL TEST RESULTS Apparent Diff. Line Pressure PSI App. Diff. Line Pressure PSI No. 1 Check Valve Differential PSID No. 1 Check Valve Differential PSID Relief Valve Opening PSID Relief Valve Opening PSID No. 1 Check Valve: PASSED: No. 1 Check Valve: PASSED: FAILED: FAILED: HOLDS TIGHT No. 2 Check Valve: HOLDS TIGHT FAILED: FAILED: Minimum Separation Yes No Distance as measured: inches Line Pressure: PSI Line Pressure: PSI No. 1 Check Valve: PASSED: No. 1 Check Valve: PASSED: FAILED: FAILED: No. 2 Check Valve: PASSED: No. 2 Check Valve: PASSED: FAILED: FAILED: Line Pressure: PSI Line Pressure: PSI Air Inlet Opened at PSID Air Inlet Opened at PSID Failed to open Failed to open Check Valve: PASSED: Check Valve: PASSED: FAILED: FAILED: Yes No PROPERLY INSTALLED Yes No PASSED TEST REMARKS / REPAIRS MADE: INITIAL TEST BY: WA CERT. No. B DATE: TEST EQUIPMENT MANUFACTURER: MODEL: CAL. DATE TEST AFTER REPAIR BY: WA CERT. No. B DATE: TEST EQUIPMENT MANUFACTURER: MODEL: CAL. DATE PRINTED NAME: TELEPHONE No. SIGNATURE: e-mail to: WAC 246-292-036 I CERTIFY THE ABOVE REPORT TO BE TRUE INSTALLATION: TEST AFTER REPAIRS OR CLEANING DCVA DCDA DCDA II RPBA RPDA RPDA II No. 2 Check Valve: SVBA AG PVBA SERIAL No. [EMAIL REDACTED] SERIAL No. TYPE OF ASSEMBLY: RESET FORM SIGN