T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

18438

2

RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

irrigation

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Pool pump room

✔

009 M2Watts

0✔

80

09141143

RP

10:52 AM

Parc at University Tower

8 2 1 8

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A940818RWCT0548

✔

Shut off valve #1 needs a new handle

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 1100 riser room

✔ ✔

805YFebco

✔

80

09141143

DC

1:21 PM

Parc at University Tower

2 4 1 2

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A100976RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 1000 riser room

✔ ✔

805YFebco

✔

80

09141143

DC

1:02 PM

Parc at University Tower

2 6 1 4

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

H13630RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 900 riser room

✔ ✔

850Febco

✔

80

09141143

DC

12:54 PM

Parc at University Tower

2 4 2 6

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A100942RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 800 riser room

✔ ✔

805YFebco

✔

80

09141143

DC

12:36 PM

Parc at University Tower

2 0 1 8

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

✔

Sep 13th 2016

A041929RWCT0548

✔

Check Valve #2 needs to be replaced. Shut off valve #1 needs a new handle.

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 700 riser room

✔ ✔

805YFebco

80

09141143

DC

12:14 PM

Parc at University Tower

1 4 0 0

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A033761RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 600 riser room

✔ ✔

805YFebco

✔

85

09141143

DC

12:09 PM

Parc at University Tower

2 2 1 8

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A033772RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 500 riser room

✔ ✔

805YFebco

✔

85

09141143

DC

11:51 AM

Parc at University Tower

2 2 2 4

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

✔

Sep 13th 2016

A027097RWCT0548

✔

Check Valve #2 needs to be replaced.

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 400 riser room

✔ ✔

805YFebco

85

09141143

DC

11:37 AM

Parc at University Tower

1 6 0 0

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A033765RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 300 riser room

✔ ✔

805YFebco

✔

85

09141143

DC

11:20 AM

Parc at University Tower

2 0 2 2

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A033771RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 200 riser room

✔ ✔

805YFebco

✔

85

09141143

DC

11:09 AM

Parc at University Tower

1 8 1 6

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

3/4"

✔

Sep 13th 2016

3613177

2

RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

irrigation

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Hotbox at main entrance

✔

975XLWilkins

4✔

85

09141143

RP

11:01 AM

Parc at University Tower

10 6 2 8

T&M Rev:03.12.2015

(Required on New Installs)

(Required for Cert. of Occupancy)

City of Durham Cross Connection Control 1600 Mist Lake Drive; Durham, NC 27704 Ph. (919) 560-4194 Fax. (919) 560-1744 Email: cccprogram@durhamnc.gov

Backflow Prevention Assembly Test and Maintenance Report

Name of Owner: BUILDING PERMIT NO:

Mailing Address: BACKFLOW PERMIT NO:

City, State & Zip Code:

Location of Assembly:

Service Meter Number: By-pass Meter Reading:

Type: Manufacturer: Model: Size: Serial No:

Tester: Certification No: *Date: Time:

Type of Service: New Test: Recertification Test: Line Pressure:

Test Kit: Serial No: Calibration Date:

NO. 1 CHECK VALVE NO. 2 CHECK VALVE RELIEF VALVE PRESSURE VACUUM BREAKER

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Leaked

Closed Tight

Diff Pressure Across

Check Valve ___.___PSID

Opened at

____.____ PSID

Did not Open

Air Inlet ____.____ PSID

Did not open

Check Valve ____.____PSID

Leaked

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Cleaned

Replaced

(list parts in comments)

Closed Tight at ___.___PSID

Closed Tight at ___.___PSID

Opened at ____.____PSID Air Inlet ____.____PSID Check Valve ____.____PSID

Shut Off Valve #1 Leaked Closed Tight

Buffer:

Shut Off Valve #2 Leaked Closed Tight

Comments:

Assembly Status: PASSED **FAILED

I hereby certify that this data is accurate and reflects the proper operation and maintenance of the assembly.

(Signature of Licensed Tester and Date) (Company Name)

*Test and Maintenance Report must be submitted within 15 days. **All Repairs must be made within 10 Business Days.

1 1/2"

✔

Sep 13th 2016

A027115RWCT0548

✔

✔

20 Morcroft Lane

Sep 9th 2016Mid-West 845-5

fire

Durham, North Carolina, 27705

Unifour Fire & Safety

Matt Shambley

Bldg 100 Riser Room

✔ ✔

805YFebco

✔

85

09141143

DC

10:30 AM

Parc at University Tower

2 2 1 8