214 Backflow Test.tif i
ackflow Device Test Report
w 402.504.7807 • e -mail: customer service @mudomaha.com website: www.mudomaha.com j
METROPOLITAN
ur - tir,es J15TRICT Return to: Metropolitan Utilities District, 1723 Harney St., Omaha, NE 66102
— i
Name:
Bus /Owner: Y 9 Test completed
Address: JOE_ 9 ❑ Test failed
Account No. ❑ Retest after repair
❑ Annual Test W New Installation
❑ Relocate Old serial
❑ Replacement
Manufacturer: Location: c ,
Model: 'Contact person: to Vio-o Yhmaq,:�
Serial #: �c� Repair information: _
Device type: 1� _
Size:
Reduced Pressure — Double Check Valve Presswe Vacuum Breaker
Relief valve (RP only) opened at PSID Shut off #2 Held yes ❑ no
Check valve #1 PSID Held ❑ yes ❑ no Shut off #1 Held yes ❑ no
Check valve #2 PSID Held ❑ yes ❑ no Check valve Held at PSID
Shut off #2 Held ❑ yes ❑ no Air vent opened at _ PSID
Prevents backflow from:
❑ Carbonator ❑ Water cooled compressor ❑ Photo developer or x -ray ❑ Humidifier
Lawn sprinkler ❑ Food processing ❑ Boiler makeup ❑ Cooling tower
❑ Dry cleaning ❑ Mortuary ❑ Laboratory or hospital ❑ Vacuum pump
❑ Fountain ❑ Swimming pool ❑ Chemicals ❑ Service containment
❑ Other (describe): _
I hereby certify 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 the Metropolitan Utilities District, and that all reading are true and accurate to the
best of my knowledge,
State certified technician (please print) P S A Certificate # Date of test
State certified technician (signature) 11A C omer (signature)
Employer of state certified technician (JC ( � tl e Phone: te 1 Fax:
Test gauge manufacturer Test gauge serial # Date calibration verified Accuracy verified by
1624 (101712t1c)'