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PERMIT DOCUMENTS 9 1 Buckeye Plumbing Services, Inc. 310 BUSINESS PARK WAY �'"°' ° un WEST PALM BEACH, FL 33411 1/4 , (561) 282-5393 Fax:(561) 791.1853 I backflow@callbuckeye.com Backflow Division Customer Name: HUGHES CONSTRUCTION -- V Street Address: 1000-1070 AUDACE AVE. Passed Mailing Address: BOYNTON BEACH FL 33426 Failed Device Location: /1/C^ TRti 5– Q New r/ Account Number: // Replaced Meter Number: , '57 2S s.)-- Meter Reading: Manufacturer: ,47,..4dModel: 3croYo SS Serial#://°6e 0--- Size: /❑ Containment ❑ Isolation RP ❑ DC Q PVB ❑ AVB ❑ AG ❑ Line Pressure: Test Date: 6/ 7 Check Valve#1 Check Valve#2 Differential Pressure Vacuum Pressure Relief Valve Breaker 1.Closed Tight © 1.Closed Tight 0 Opened At PSI Air Inlet Initial Opened PSI ❑ 2.Leaked ❑ ❑ Did Not Open ❑ Test 2.Leaked Did Not Open p 3.Gauge Pressure Across 3.Gauge Pressure Across Check Valve o..)•O PSI Check Valve a)•y PSI Held At PSI Cleaned ❑ Cleaned 0 Cleaned ❑ Check Valve PSI Replaced: Replaced: Replaced: Leaked 0 R Rubber Parts Kit ❑ Rubber Parts Kit ❑ Rubber Parts Kit ❑ Cleaned 0 E ' C.V. Assembly ❑ C.V. Assembly 0 R.V. Assembly ElReplaced: P i or or or C.V.Assembly ❑ A Disc Disc 0 Disc ❑ Disc. Air Inlet 0 I 0-Rings 0-Rings DiaphraDisc. C.V. ❑❑ R Seat H Seat 9 rru ID ❑ Spring S Retainer 0 Spring ❑ Spring ❑ Spring ID ❑ Stem/Guide 0 Stem/Guide ❑ Guide El Guide Retainer Retainer 90-Rings ❑ Lock Nuts ❑ Lock Nuts H Lock Nuts Other ❑ 0-Ring 00 Other 0 Other Other ' Closed Tight Closed Tight —Opened-At Psi Satisfactory ❑ Reduced Pressure All Repairs/Replacement Shall Be Completed Within Ten (10) Days. Remarks: Test Kit Info: Midwest,Model 845-5, Serial#11110945 I hereby certify that this data is accurate and reflects the proper operation and rreintenance of the unit. Certified Testing Company: ra-- — IMonth Day Year InitiallTest By: GREGORY B. POPE Certification No. Q 09-15-7034 Date: 12/31/2017 Repaired By: GREGORY B. POPE Certification No. 0 09-13-7034 Date: Final Test By: Certification No. I s 1 F d Q Ii 0 Date: [ 9 It Office 561-822-2240 Fax 561-822-2259 FieldCustomerService@wpb.org Page 1