Backflow Prevention Assembly Test Report - KC Water

1 Reduced Pressure Principle Assembly Double Check Valve Assembly Air Gap Required SeparationInitial Test Date _____ Time_____Leaked Closed Tight Held at_____PSIDR epairs Date _____ Time_____ Cleaned Replaced Final Test Date _____ Time_____Notify us if failed assemblies cannot be repaired within three :_____ _____Service AddressMailing AddressReturn completedTest Report to:Kansas City Water Services2409 E. 18th St. Kansas City, MO 64127 Phone: 816-513-4795 Fax: 816-513-4798 Email: #:Manufacturer:Model:Type:Size:Orientati on:Protection:Check if Correct Corrections_____Hazard: _____ Meter#: _____ Premise ID:_____ SPID:_____ Test Due No Later than:ExistingNewRemovedReplacedCommercia lIndustrialResidentialConstructionDomest icIrrigationFireYe sNoPVB/SVBC heck Valve #1 Check Valve #2 Relief ValveAir InletCheck ValveLeaked Closed Tight Held at_____PSIDDid not open Opened at ____ PSIDDid not open Opened at ____ PSIDLeak Held at ____ PSIDC leaned Replaced Cleaned Replaced Rubber Kit RV Assembly Disc Diaphram(s)

2 Seat Spring Guide O-rings Other Closed Tight Held at ____ PSIDC losed Tight Held at ____ PSID Opened at ____ PSID Opened at ____ PSID Held at ____ PSIDC leaned Replaced Cleaned Replaced Rubber Kit Disc Spring Retainer Guide O-ringsOther Rubber Kit CV Assembly Disc Spring Retainer GuideO-rings Other Yes NoI certify all information on this Report is true and accurate, acknowledging that incomplete reports will not be Certification #_____ Phone _____ Test Kit Serial # _____ Calibration Date _____ Signature _____Proper InstallationRV Exercised #2 Shutoff ClosedService RestoredLine Pressure _____ Meter Reading _____Passed Failed_____Mailing Phone _____Rubber Kit CV Assembly Disc O-rings Seat Spring Stemguide Retainer Lock Nuts OtherRubber Kit CV Assembly Disc O-rings Seat Spring Stemguide Retainer Lock Nuts Other Backflow Prevention Assembly Test Report