Fillable Form 28792: 305 William Street Hendersonville, NC Prevention (City of Hendersonville)

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Form 28792: 305 William Street Hendersonville, NC Prevention (City of Hendersonville)

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The Form 28792: 305 William Street Hendersonville, NC Prevention (City of Hendersonville) form is 1 page long and contains:

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  • 45 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Hendersonville

BROWSE CITY OF HENDERSONVILLE (NC) FORMS

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Customer:_____________________________________________________________ _______ __
Property Address:__ __________________________________________________________
Mailing Address:_____ _
__________________________________________________________
Phone Number: _______ _
_____________ Meter No. ________________________________
Service Type: Domestic Irrigation Fireline Combination (Domestic and Fireline)
Assembly Type: RP DC PVB Assembly Size:___________ __________
Manufacturer:_ ________________ Model:_____ _______ Serial No._____ _______________
Assembly Location:__ _________________________________________________________
Contact Person: __________________________ _____________ Line Pressure: ______ ____ psi
CHECK VALVE #1
RELIEF VALVE
CHECK VALVE #2
PRESSURE VACUUM
BREAKER
Leaked
Closed Tight
Differential Pressure Across
Check Valve_______ psid
Opened @________ psid
Did Not Open
Buffer______ psi
Leaked
Closed Tight
Differential Pressure Across
Check Valve _______ psid
Air Inlet Opened
@________psid
Did Not Open
Checked Valve: Leaked
Held @_____psid
Cleaned Only
Replaced Rubber Kit
Replaced CV Assembly
Other (Details) -
Cleaned Only
Replaced Rubber Kit
Replaced CV Assembly
Other (Details) -
Cleaned Only
Replaced Rubber Kit
Replaced CV Assembly
Other (Details) -
Cleaned Only
Replaced Rubber Kit
Replaced CV Assembly
Other (Details) -
Closed Tight
Differential Pressure Across
Check Valve________ psid
Opened @_________ psid
Buffer______ psi
Closed Tight
Differential Pressure Across
Check Valve________ psid
Air Inlet______psid
Check Valve______ psid
Shut-Off No. 1
Leaked Held Tight
Shut-Off No. 2
Leaked Held Tight
Assembly Test Results: Passed Failed Repairs must be completed with 14-days.
Remarks:__________________________________________________________________________________________________
___________________________________________________________ _
____________________________________________
Kit: Diff. Dupl. Elec. Manufacturer:______ ______ Model:____________ Serial No.________________
I hereby certify that the data is accurate and reflects proper operation and maintenance of assembly.
Tester’s Name
_________ _________ Signature _____________ __________ Certification No. _ ______________
Test Date:_______________ Time: _________________ am pm Tester’s Phone # ___________________
Mail results to above address.
305 William Street
Hendersonville, NC
28792
Backflow
Prevention
Assembl
y
Test
Office use only:
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Form 28792: 305 William Street Hendersonville, NC Prevention (City of Hendersonville)

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Completed 3 August 2020

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