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Get Backflow Testing Near Me

BACKFLOW PREVENTER TEST REPORT Cross Connection Control - 4693 Rochester Rd Troy MI 48085-4928 248-524-3398 Desk 248-524-1541 Fax 248-524-3370 Ofc Property Occupant Service Address Office Phone No. Contact Suite City Zip Fax TROY State MI Name Mailing Address Ext. St / Zip Assembly Manufacturer Model Serial Number Application Other I. D. No. Size of Assembly Type of Assembly Location Fire System Downstream Static Riser Pressure Before Testing - First Test Date Pass Test Gauge Make 1 Shutoff C L N/A 1 Check C 3-Hose BP PSID Check Valve Direction of Flow DOF Test DOF PSID Notes PM Supply Line Static Pressure Last Annual Certification Vacuum Breaker pvb or svb Double Check or Reduced Pressure Assembly DOF ASSE 1047-48 Bypass Single Check DOF psid Check Valve Backpressure BP Test Per ASSE 5000 testing standards Verify Proper Installation - Pass AM Serial Time of Test Fail Relief O M Air Inlet O Drip Test Only psid Relief Valve Flushed PSID BackPressure Test - Pass Returned to service - Valves On Relief Full Open Test Removed from service-Valves Off Fire Valves Locked After Test Yes No No Locks NFPA25 Fire System Main Drain Test Performed to verify all valves are left open ALL FAILED ASSEMBLIES MUST BE REPAIRED WITHIN 15 DAYS Second Last Test Testing Company Address Phone Tester s Name Backflow Cert Tester Signature MI Plumbing License Plumbing Contractor Lic The above results were true at the date and time of testing. BACKFLOW PREVENTER TEST REPORT Cross Connection Control - 4693 Rochester Rd Troy MI 48085-4928 248-524-3398 Desk 248-524-1541 Fax 248-524-3370 Ofc Property Occupant Service Address Office Phone No* Contact Suite City Zip Fax TROY State MI Name Mailing Address Ext. St / Zip Assembly Manufacturer Model Serial Number Application Other I. D. No* Size of Assembly Type of Assembly Location Fire System Downstream Static Riser Pressure Before Testing - First Test Date Pass Test Gauge Make 1 Shutoff C L N/A 1 Check C 3-Hose BP PSID Check Valve Direction of Flow DOF Test DOF PSID Notes PM Supply Line Static Pressure Last Annual Certification Vacuum Breaker pvb or svb Double Check or Reduced Pressure Assembly DOF ASSE 1047-48 Bypass Single Check DOF psid Check Valve Backpressure BP Test Per ASSE 5000 testing standards Verify Proper Installation - Pass AM Serial Time of Test Fail Relief O M Air Inlet O Drip Test Only psid Relief Valve Flushed PSID BackPressure Test - Pass Returned to service - Valves On Relief Full Open Test Removed from service-Valves Off Fire Valves Locked After Test Yes No No Locks NFPA25 Fire System Main Drain Test Performed to verify all valves are left open ALL FAILED ASSEMBLIES MUST BE REPAIRED WITHIN 15 DAYS Second Last Test Testing Company Address Phone Tester s Name Backflow Cert Tester Signature MI Plumbing License Plumbing Contractor Lic The above results were true at the date and time of testing.

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