Backflow Test.tifService Type: ❑ Annual Test .0 New Installation ❑ Replaced Device ❑ Relocated Device
Device Type: ❑ DCr , ElRPP ;KPVB R
Size: / 11 Manufacturer: t� t 1. Model: ��i �1 ” Serial #: 6 Z-1 610
Location at Property: i }r : e- 9 1^!v i'2' Repair Notes if Applicable:
Old Serial # & Make (if replaced): A/ Original Location (if relocated):
City of Blair
i° a$ e
b„:#
J
° a
218 S. 16th St.
—
30101011imm
Blair, NE 68008
Held at PSID
Held at PSID
Phone: (402) 426-4191
Fax: (402) 426-4196 Email: shellyj&l.blainnems
-00
14
Leaked ❑ YES ❑ NO
Closed Tight ❑ YES ❑ NO
Did not open
Opened at PSID
Cleaned
Leaked ❑ YES ❑ NO
Cleaned
Owner/Contact Name:
Phone #:
2 Test completed
Replaced
Business Name: AWA
Check Valve
❑ Test failed
#2 Shut Off
Closed Tight ElYES ElNO
Service Address: �'p ( 7 �''� ��'
Held at PSID
Leaked
❑ Retest after repair
Account No.
Service Type: ❑ Annual Test .0 New Installation ❑ Replaced Device ❑ Relocated Device
Device Type: ❑ DCr , ElRPP ;KPVB R
Size: / 11 Manufacturer: t� t 1. Model: ��i �1 ” Serial #: 6 Z-1 610
Location at Property: i }r : e- 9 1^!v i'2' Repair Notes if Applicable:
Old Serial # & Make (if replaced): A/ Original Location (if relocated):
Check Valve #1
Check Valve #2
Pressure Relief Valve
PVB/SVB
INITIAL TEST
XMINNEREMM
30101011imm
am=
Held at PSID
Held at PSID
Opened at
PSID
Air Inlet
Leaked ❑ YES ❑ NO
Closed Tight ❑ YES ❑ NO
Did not open
Opened at PSID
Cleaned
Leaked ❑ YES ❑ NO
Cleaned
Did not open
Replaced
Cleaned
Replaced
Check Valve
T
#2 Shut Off
Closed Tight ElYES ElNO
Held at PSID
Leaked
=�
Cleaned
Replaced
r ,
FINAL TEST
Closed Tight ❑YES ONO
lReplaced
PSID
Check Valve k PSID
Air Inlet q JI PSID
PSID
PSID
Prevents backflow from:
❑ Carbonator ❑Water cooled compressor ❑Photo developer
® Lawn Sprinkler' ❑ Food•processing ❑ Boiler makeup
❑ Dry cleaning ❑ Mortuary ❑ Laboratory or hospital
❑ Fountain ❑ Swimming Pool ❑ Chemicals
❑ Fire Service ❑ Domestic Containment ❑ Ice Maker-
❑ .Humidifier
❑ Cooling tower
❑ Vacuum pump
❑ Service containment.
❑ Other
Forward Flow Information for assemblies in Fire Protection Systems (include inside hose demand if applicable).
System Demand Actual Flow Rate Connection Type
Indicating Control Valves: Valve Supervision:
❑ #1 Valve Open 0#2 Valve Open ❑Locked Damper Switch
I hereby certify that the above backflow preventer has been tested in accordance with all rules and regulations, of the State of Nebraska
_ Health and Human Services, Department of Regulation and Licensure, Title 179, and that all readings are true and accurate
to the best of my knowledge.
State certified technician (please print)
Statertifie echnician (signature)
Test gauge manufacturer
Test gauge serial #
Customer
1I
10-L� B7a9 ' B /)/-
Certificate # `D7ate of Test
C— -r X - /- - 1G
Date calibration verified
Date
Accuracy verified by