DDW-2025-003159

Service #
BACKFLOW ASSEMBLY TEST FORM
Type of Assembly:RP DCV PVB SVB Other:
Location of Assembly: PuMP HoUSE
Address of Assembly:
Owner of Assembly:
Mailing Address:
Make: Ames Model: DC 200 Size: O"Serial Number: UJ- 1781
Assembly Status:Existing ☐
Type of Protection: Isolation ☐Zone
CHECK VALVE # 2
Assembly connected to what equipment: Fite System
CHECK VALVE # 1
Replacement ☐
Containment ☐
New
Fire RP☐DCV PVB SVB
DP RELIEF VALVE
PVB
SVB & PVB AIR INLEТ
I
N
I
T
I
A
L
T
E
S
T
PSI Across 2.4 PSI Across 4 Opened @ PSI Opened @ _PSI
Closed Tight ☐Closed Tight Closed Tight Π Closed Tight Π
Leaked Leaked Π Did not open Π
Leaked 미
Did not open☐Leaked 미
R
E
P
A
I
R
S
Parts - Cleaned Installed Parts- Cleaned Installed Parts - Cleaned Installed Parts - Cleaned Installed
Disk ☐D Disk Π Disc Π Π
Spring ☐미 Spring☐Diaphragm Air Inlet
Disk
Guide ☐마 Guide ☐미 Spring
Seat Seat Π Guide ◉ ☐Air Inlet
O-Rings ☐미 O-Rings Π Seat
All Parts All Parts Π All Parts
O-Rings Π
Spring
All Parts
Other: ☐ ☐Other: ☐
Describe:Describe:
Other: ☐ ☐
Describe:
Other: ☐ ☐
Describe:
PSI Across PSI Across Opened @ PSI
Closed Tight Π Closed Tight Closed Tight
Leaked Π Leaked ☐Leaked ☐
Assembly:Passed ☑ Date: 3-12-25
Opened @ _PSI
Closed Tight
Did not open☐
Failed ☐Date:
Comments:
InitialTestBy:DUSTY HOBBS Final Test By:
Repaired By:
Test Kit Make:
Tester Signature:
Date:
Model #Serial #Calibration Date:
UT Tester #: 45-2302325 Tester Telephone #: [phone]
I certify the above test has been performed and I am aware of the final performance.
Device Owner Representative:Date:
Mail Report to:Salt Lake City Public Utilities
Cross-Connection Section
1530 South West Temple Street
Salt Lake City, UT 84115
Phone #
Phone#
[phone]
[phone]
E-mail: [e-mail]