1904 Backflow Test.tifSep.25' 2015 9.33AM WIESE PLUMBING No.96$$ P. 1
Feb. 11. 2015 11.26AM CITY OF BLAIR (402, 426. 4191) No, 6792 Q- 2
city of Emir
218 S. 16th St
Biair, NE 68008
Parana; (402) 426-4191 Fax: (402) 426.4196 Email: Sheilyj&i,biainne.us
O,vncr(ContactNRme=
41f.1 f 5 90il ti Pltono#: Te$t completed
l�asitressl�e>ite' Test failed
Scrvico Address: c t 97i ' ir't f Ni. ( y [ Ralost n[ter rcnuir
account No.
Setvice TI pe: 0 Annuel T'rsr N"";' Inslollerian I eplactd Tlevice ❑ Refocarsd]]evite
DtActTypo ❑ DC Q Rpp P'VB
sin; ManufarAtlrcr: Model; o M6crial #: _C 7 2c,
Location at Property: V G9 � )
I`zopakNa(esifApplicablc:
Old Serial # & Make Ofreplaced): r glnpt 14Cation (ifratoc 3Ted}: b
Check Valve #I Check Valve#2 PressurcReliotValve Y SAYE
Iid%`I'IAL TEST — —
Held at PSl1] Hold at PSID Qponed tit 1}STT7 Air Inlet
beaked ❑ YES ❑ NO Closod Tight ❑ Y1*S❑ No Did not open O erred as f PSS
Cleaned lLe k d M YES ❑ NO Cleaned l7id not opm
rcG lseed cleanaa r�epl ctd _ Checkvalve
$11111 Oft`
CloscdTight ❑�'ES❑NO � Fielditt PSID
xk Ind /V
Cleaned AlC�
• r::: Ftcplacad �
FINAL "i'Z<S1` Cinsed Tight iS 0gO e
Chrok'Valvc 'F PSiD
PSID PSID Roplaecd ?SID jAkWet 11 PSID
PrevenTs backflow from:
❑ Carbonator 0 WaTcr cooled compressor ❑ Photo developer ❑ Humidifiier
§<UWASprinkier' ❑ Food'processing 0 Boilermakimp C001111gtower
❑ Dry cleaning ❑ Mortuary ❑ I-aborworyarhaspital ❑ 'VgcUvmgump'
❑ Follatain ❑ Swimmin poc-1 ❑ Chemicals ❑ Service containment
❑ Fire Service ❑ Domestioconmituttent ❑ Icewker ❑ Other
Narward Flow Information for assemblies In Fire Protectloa Systems (Include luslae host dernAnd 1f applicable).
System Demand Actual Flow Rat o Ounntclion Type,
eating Control Valves Valve Supervision:
❑ :7 Valve U en �� Vsly� i� �n ❑Locked C]'am �r Slvltch
I hereby csniig 11181 The abOVO backflow pteventer hes been lasletl en accord iro Wim All ru'w Zulu iugunauuuo, Va u,U y kq" w�.,��•�,� ,
Health and Flunlau SeMws% Department of Rcgulation and LirxnsuM Titie 179, -"'4 that all roadings azes true and accarare
to Tho best of my knowlcdgo.
STat c ified [ethnitian (please print} CmupatlyNpene Phone 4 Data of Test
Stara certified 1cchnioian(signaturo) CusTomer(&l naturo) Date i
1 arf It c 7
les[ gauge rnanufacrumr
Test gauge serial #
Dart c4bradou verified AccUrdol+ vc61710 by