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PERMIT DOCUMENTS c! Buckeye Plumbing Services, Inc. ( 310 BUSINESS PARK WAY // J, (�/5- 17 WEST PALM BEACH, FL 33411 (7 J �`� (561) 282-5393 Fax:(561) 791-1853 backflow@callbuckeye.com Backflow Division Customer Name: HUGHES CONSTRUCTION Street Address: 1000-1070 AUDACE AVE. Passed Mailing Address: BOYNTON BEACH FL 33426 Failed Device Location: 5C 6/0 New V Account Number: Replaced Meter Number: :7ny' _ _ . • Meter Reading: Manufacturer:7d.dhiLe Model: t/ 7 t_X L Serial#: 73,V/l3 C Sizer ' ' j[/] Containment 0 Isolation RP ❑ DC ❑ PVB ❑ AVB ❑ AG ❑ Line Pressure: Test Date: 1—js//7 Check Valve#1 Check Valve#2 Differential Pressure Vacuum Pressure Relief Valve Breaker Initial 1.Closed Tight Z 1. Closed Tight © Opened At o7. to PSI Air Inlet Opened PSI 2. Leaked ❑ 2. Leaked ❑ Did Not Open ❑ Did Not Open ❑ Test 3.Gauge Pressure Across 3.Gauge Pressure Across Check Valve c Sl PSI Check Valve A 7 PSI Held At PSI Cleaned 0 Cleaned 0 Cleaned ❑ —Check Valve PSI Replaced: Replaced: Replaced: Leaked 0 R Rubber Parts Kit ❑ Rubber Parts Kit 0 Rubber Parts Kit ❑ Cleaned ❑ E C.V. Assembly ❑ C.V.Assembly ❑ R.V.Assembly ❑ Replaced: Por or or C.V. Assembly 0 A Disc ❑ Disc ❑ Disc El Disc. Air Inlet 0 I 0-Rings 0-Rings Diaphram 0 Disc. C.V. ❑ R Seat 9 Seat H Seat ❑ Spring ❑❑ S Spring ❑ Spring B Spring 0 Retainer Stem/Guide ❑ Stem/Guide Guide 0 Guide 0 Retainer Retainer 0-Rings 0 Lock Nuts El Nuts 9 Lock Nuts 9 Other 0 0-Ring 0 Other 0 Other 0 Other 0 OClosed Tight Closed Tight Reduce Pressure ened AtPSI Satisfactory 0 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 maintenance of the unit. Certified Testing Company: _ e_ Wall) Day Yea, Initial Test By: GREGORY B. POPE Certification No. Q 09-15-7034 Date: 12/31/2017 Repaired By: GREGORY B. POPE Certification No. Q 09-15-7034 Date: Final Test By: Certification No. IIIIIIII Date: I L I Offibe 561-822-2240 Fax 561-822-2259 FieldCustomerService@wpb.org Page 1