Backflow Preventer Test and Maintenance Report (Print)
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10 JOHNSTON COUNTY INSPECTIONS DEPARTMENT 309 E MARKET STREET SMITHFIELD , NC 27577 PHONE 9199895060 FAX 9199895431 BACKFLOW PREVENTER TEST & MAINTENANCE REPORT CUSTOMER CONTACT NO ADDRESS OF PROPERTY MAILING ADDRESS LOCATION OF ASSEMBLY TYPE OF ASSEMBLY MANFACTURER RP DC PVB MODEL SIZE _______________________ SERVICE NO ___________________ SERIAL NO TYPE OF SERVICE DOM IRRIG COMBINATION DOM & FL CHECK VALVE # 1 RELIEF VALVE RELIEF VALVE PRESSURE VACUUM BREAKER LEAKED CLOSED TIGHT DIFF PRESSURE ACROSS CHECK VALUE __________ PSID OPEN AT ___________ PSID DID NOT OPEN LEAKED CLOSED TIGHT DIFF PRESSURE ACROSS CHECK VALUE __________ PSID AIR INLET OPENED AT __________ PSID DIDNT OPEN CHECK VALVE LEAKED HELD AT __________ PSID CLEANED ONLY CLEANED ONLY CLEANED ONLY CLEANED ONLY REPLACED REPLACED REPLACED REPLACED RUBBER KIT RUBBER KIT RUBBER KIT RUBBER KIT CV ASSEMBLY CV ASSEMBLY CV ASSEMBLY CV ASSEMBLY DISC DISC DISC DISC O - RINGS O - RINGS O - RINGS O - RINGS SEAT SEAT SEAT SEAT SPRING SPRING SPRING SPRING STEM GUIDE STEM GUIDE STEM GUIDE STEM GUIDE RETAINER RETAINER RETAINER RETAINER LOCK NUTS LOCK NUTS LOCK NUTS LOCK NUTS OTHER OTHER OTHER OTHER CLOSED TIGHT DIFF PRESSURE ACROSS CHECK VALUE __________ PSID OPEN AT ___________ PSID CLOSED TIGHT DIFF PRESSURE ACROSS CHECK VALUE __________ PSID AIR INLET _________ PSID CHECK VALVE _______ PSID NOTE ALL REPAIRS MUST BE COMPLETED WITHIN 10 DAYS REMARKS _________________________________________________________________________________________________________ TEST KIT SERIAL NO ______________ MANUFACTURER _________________ DIFFERENTIAL DUPLEX ELECTRONIC I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE ASSEMBLY TIME OF TEST _______________________ DATE ___________________________ AGENT ______________________________________________________________________ CERTIFICATION NO __________________Page