PERMIT DOCUMENTS Backflow PlumbingI
310 Business Parkway l(O i /,,
West Palm Beach, FL 33411 e, :,.a,' ""�=2=I, . enut I�'
Office(561) 333-5649
Fax(561)791-1853
backflow@callbuckeye.com Backflow Division
CUSTOMER NAME: Qt&&i ( -'Je3 e_ ?r4.2eS S /c nat f Pa,
STREET ADDRESS: 2 609 LOOC/a7.5/CF �, PASSED ..�
MAILING ADDRESS: FAILED
DEVICE LOCATION: S•ti-O • C&rps - Pt 40 NEW ------
ACCOUNT NUMBER: REPLACED
METER NUMBER: So Z19O{, , METER READING: ,
MANUFACTURER: MODEL: 7VBA FV'/4 SERIAL NO: 82 p2 /U SIZE
CONTAINMENT ❑ ISOLATION
RPO DC 0 PVBEIV AVBD AGO
LINE PRESSURE: 6S TEST DATE: 4' 2/'/ 7
CHECK VALVE 01 CHECK VALVE 02 DIFFERENTIAL PRESSURE VACUUM
PRESSURE RELIEF VALVE BREAKER
INITIAL I.CLOSED TIGHT 0 I.CLOSED TIGHT 0 OPENED AT PS AIR INLET
OPENED A ' PSI
TEST 2.LEAKED 0 2.LEAKED 0 DID NOT OPEN C DID NOT OPEN 0
3.GAUGE PRESSURE ACROSS 3.GAUGE PRESSURE ACROSS
CHECK VALVE PSI CHECK VALVE PSI HELD AT 2•ZPSI
CLEANED 0 CLEANED 0 CLEANED C CHECK VALVE PSI
REPLACED: REPLACED: REPLACED LEAKED 0
R RUBBER PARTS KIT 0 RUBBER PARTS KIT 0 RUBBER PARTS KIT C
E C.V.ASSEMBLY ❑ C.V.ASSEMBLY ❑ R.V.ASSEMBLY C CLEANED ❑
P OR OR OR REPLACED:
A DISC I 0 DISC ❑ DISC C C.V.ASSEMBLY 0
I 0-RINGS 0 0-RINGS 0 DIAPHRAGM C DISC.AIR INLET ❑
R SEAT 0 SEAT SEAT C DISC.C.V. ❑
S SPRING 0 SPRING 9 SPRING C SPRING 0
STEM/GUIDE 0 STEM/GUIDE GUIDE C RETAINER 0
RETAINER ❑ RETAINER ❑ 0-RINGS C GUIDE 0
LOCK NUTS 0 LOCK NUTS ❑ i OTHER C 0-RING 0
OTHER 0 OTHER 0 OTHER 0
OPENEDPSI
CLOSED TIGHT CLOSED TIGHT REDDUCEDCED PRESSURE (SATISFACTORY In.
ALL REPAIRS/REPLACEMENT SHALL BE COMPLETED WITHIN TEN(10)DAYS. /Oa)4 '/
REMARKS: MIDWEST 845-5 KIT SERIAL NUMBER 11140491 6125115-6125116 / 'S ( JF
s/est 75'Si,5-
I
I HEREBY CERTIFY THAT THIS DATA IS ACCURA AND REFLy TS THE PROPER OPERATION AND MAINTENANCE OF THE UNIT.
CERTIFIED TESTING CO Y
�' ` MONTH DAY YEAR
INITIAL TESTS . i•OSCOE L :jr CERTIFICNt,ON NO. Q 101 91 1 5 11 0 91 9 DATE: 9 30 17
MONTH DAY YEAR
REPAIRED BY: ROSCOE L SMITH CERTIFICATION NO. R 101 1 6I 0 I I DATE: 9 30 17
IMONTH DAY YEAR
FINAL TEST BY: ROSCOEIL SMITH CERTIFICATION NO. Q 0 9 1 5 1 0 9 9 DATE: 9 30 17
Office 561-822-2240 Fax 561-822-2259-FieldCustomerService@wpb.org Page 1