KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

(1)

KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

Name of Premise: Contact: .

Service Address: Postal Code: .

Owners Address: Postal Code: .

Assembly: .

Manufacturer Model # Serial # Type Size

Assembly being tested: New Replacement Annually Line Pressure at time of testing: psi

Reduced Pressure Assemblies Pressure Vacuum Breaker

Double Check Assemblies Air Inlet Check Valve

1

^st

Check 2

^nd

Check Relief V Buffer Open at

(A) (B) (A-B=C) psid psid

D-C Closed Tight Close Tight

R-P Pres. Drop ____ psid. _ psid ___ psid did not open

Initial Confirmation Test

Passed Passed opened fully Leaked

Test Yes No Yes No

Leaked Leaked Failed Failed

D-C Closed Tight D-C Closed Tight Opened at Opened at

Test psid psid Opened at Pressure drop

After R-P pres. Drop psid

Repair Confirmation Test psid psid

Yes No Yes No Passed Passed

Air Gap Inspection: required minimum air gap separation provided? YES NO

I ________________certify this report true. Signed: Date _ d _ m _ y Certificate # Water Purveyor Water service restored? YES NO Business Address: _______________________Postal Code _ Ph. ____________

Location of Backflow Preventer _ Serves ________

Email Test Report To: [email protected] Address: City Of Kelowna, 951 Raymer Ave, Kelowna, BC V1Y 4Z7 West Kelowna

Kevin Rahn

163883 RP40

Apollo

V 2121 Louie Drive, West Kelowna, BC

Hub Centre North Bldg F

2"

RPBA

Mechanical room

(250) 860-3991 V1X 7K1

#3, 2250 Leckie Road, Kelowna, BC

(2)

KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

Name of Premise: Contact: .

Service Address: Postal Code: .

Owners Address: Postal Code: .

Assembly: .

Manufacturer Model # Serial # Type Size

Assembly being tested: New Replacement Annually Line Pressure at time of testing: psi

Reduced Pressure Assemblies Pressure Vacuum Breaker

Double Check Assemblies Air Inlet Check Valve

1

^st

Check 2

^nd

Check Relief V Buffer Open at

(A) (B) (A-B=C) psid psid

D-C Closed Tight Close Tight

R-P Pres. Drop ____ psid. _ psid ___ psid did not open

Initial Confirmation Test

Passed Passed opened fully Leaked

Test Yes No Yes No

Leaked Leaked Failed Failed

D-C Closed Tight D-C Closed Tight Opened at Opened at

Test psid psid Opened at Pressure drop

After R-P pres. Drop psid

Repair Confirmation Test psid psid

Yes No Yes No Passed Passed

Air Gap Inspection: required minimum air gap separation provided? YES NO

I ________________certify this report true. Signed: Date _ d _ m _ y Certificate # Water Purveyor Water service restored? YES NO Business Address: _______________________Postal Code _ Ph. ____________

Location of Backflow Preventer _ Serves ________

Email Test Report To: [email protected] Address: City Of Kelowna, 951 Raymer Ave, Kelowna, BC V1Y 4Z7 West Kelowna

Kevin Rahn

203536 40203T2

Conbraco

V 2121 Louie Drive, West Kelowna, BC

Hub Centre North Bldg F

1/2"

RPBA

Mechanical room

(250) 860-3991 V1X 7K1

#3, 2250 Leckie Road, Kelowna, BC

(3)

Backflow Prevention Assembly Test Report

Name of Premise: Contact:

Service Address: Service Postal Code:

Owner Address: Owner Postal Code:

Assembly:

Manufacturer Model # Serial # Type Size

Assembly being tested: New  Replacement  Annually  Line Pressure at time of testing: psi

Reduced Pressure Assemblies Pressure Vacuum Breaker

Double Check Assemblies Air Inlet Check Valve

1

^st

Check 2

^nd

Check Relief V Buffer Open at

(A) (B) (A-B=C) psid psid

D-C Closed Tight Close Tight

R-P pres. Drop psid. _ psid ___ psid did not open

Initial Confirmation Test

Passed Passed opened fully Leaked

Test Yes No Yes No

Leaked Leaked Failed Failed

Test D-C Closed Tight D-C Closed Tight Opened at Opened at

Test psid psid Opened at Pressure drop

After R-P pres. Drop psid

Repair Confirmation Test psid psid

Yes No Yes No Passed Passed

Air Gap Inspection: required minimum air gap separation provided? YES NO

I Certify this report true. Signed: Date: D M Y

Certificate #: Water Purveyor: Water service restored? YES NO

Business Address: Postal Code: Ph #:

Location of Backflow Preventer: Serves:

Remarks:

205633 40107T2

Conbraco

V 2121 Louie Drive, West Kelowna, BC

Hub Centre North Bldg F

Kevin Rahn

West Kelowna

Mechanical room

DCVA 1 1/2"

(4)

Westbank First Nation Backflow Assembly Test Report

Date:__________________

mm dd yyyy

Name of Premise: _ Service Address: _____________

Location of Assembly: _______ Services: Premise / Area/Zone / Fixture:

Identification: ____ / /_ / ________ / _

Type Manufacturer Model Serial Number Size

Inspection of Approved Air Gap: Inches: ___________ Pass Fail Dual Check Installed Yes (Provide SN# above)

Reduced Pressure Backflow Assembly Apparent Pressure Drop____ PSID Line Pressure Test: _ PSIG

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Test After Repair

Reduced Pressure Backflow Assembly Apparent Pressure Drop ___________ PSID

Test After Repair

I certify that I have tested the above assembly in conformance with the procedures outlined in the AWWA Canadian Cross Connection Control Manual

Testers Signature: ____________ Owner / Rep. Signature: _ Shutoff valves returned to original position.

Note:___________________________________________________________________________________________________________________________________________

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass ____ PSID _ PSID ______ PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass PSID PSID _ PSID Fail

Backflow Preventer Information

New Install

Annual Test

Removed

Serial # __________________

Replaced

Serial # __________________

Unprotected Bypass

Bypass w/ Parallel BFP’s Tester Information Name:

___________________________

Cert #: _____________________

Phone #: ___________________

Gauge Calibration: ___________

M D Y

Business Name:

___________________________

[email protected] Ph: (250) 707-3332 Fax: (250) 707-3339

Kevin Rahn 1827

2506814471

06 / 28 / 2021

Troy Life & Fire Safety

■

3.2 ■

2.2 ■

40107T2 205633 1 1/2"

60 ■

■

10 / 14 / 2021

Hub Centre North Bldg F 2121 Louie Drive, West Kelowna, BC, V

Mechanical room ■ Irrigation

DCVA Conbraco

(5)

Causes for Operation Failure

Check relevant boxes and explanation in the remarks section. Remarks (please PRINT clearly)

__________________________________________________________________

Installation or Other Irregularities

Remarks (please PRINT clearly)

__________________________________________________________________

Foreign matter introduced during construction

Sand or grit inherent to the supply system

Debris introduced fouling or damaging seats

Air entrapment

Tuberculation or rust

Abnormal rubber disc wear or cuts

Loss of interior coating

Disc retainer fractured or worn

Springs weak or broken

O-rings pinched or cut

Retainer nut

Improper machining or casting

Guide mechanism damaged

Plugged or damaged sensing line

Other

Improper assembly installed for degree of hazard

Shutoff valve(s) will not close positively

Test cocks missing from assembly

Improper (unapproved) installation

Vertical installation

Assembly replaced

Assembly no longer required

Could not test (explain below)

Other

(6)

Westbank First Nation Backflow Assembly Test Report

Date:__________________

mm dd yyyy

Name of Premise: _ Service Address: _____________

Location of Assembly: _______ Services: Premise / Area/Zone / Fixture:

Identification: ____ / /_ / ________ / _

Type Manufacturer Model Serial Number Size

Inspection of Approved Air Gap: Inches: ___________ Pass Fail Dual Check Installed Yes (Provide SN# above)

Reduced Pressure Backflow Assembly Apparent Pressure Drop____ PSID Line Pressure Test: _ PSIG

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Test After Repair

Reduced Pressure Backflow Assembly Apparent Pressure Drop ___________ PSID

Test After Repair

I certify that I have tested the above assembly in conformance with the procedures outlined in the AWWA Canadian Cross Connection Control Manual

Testers Signature: ____________ Owner / Rep. Signature: _ Shutoff valves returned to original position.

Note:___________________________________________________________________________________________________________________________________________

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass ____ PSID _ PSID ______ PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass PSID PSID _ PSID Fail

Backflow Preventer Information

New Install

Annual Test

Removed

Serial # __________________

Replaced

Serial # __________________

Unprotected Bypass

Bypass w/ Parallel BFP’s Tester Information Name:

___________________________

Cert #: _____________________

Phone #: ___________________

Gauge Calibration: ___________

M D Y

Business Name:

___________________________

[email protected] Ph: (250) 707-3332 Fax: (250) 707-3339

Kevin Rahn 1827

2506814471

06 / 28 / 2021

Troy Life & Fire Safety

2.6 ■ 7.8 5.2 ■

RP40208T2 163883 2"

■

7.8 60

■

10 / 14 / 2021

Hub Centre North Bldg F 2121 Louie Drive, West Kelowna, BC, V

Mechanical room ■ Domestic supply

RPBA Conbraco

(7)

Causes for Operation Failure

Check relevant boxes and explanation in the remarks section. Remarks (please PRINT clearly)

__________________________________________________________________

Installation or Other Irregularities

Remarks (please PRINT clearly)

__________________________________________________________________

Foreign matter introduced during construction

Sand or grit inherent to the supply system

Debris introduced fouling or damaging seats

Air entrapment

Tuberculation or rust

Abnormal rubber disc wear or cuts

Loss of interior coating

Disc retainer fractured or worn

Springs weak or broken

O-rings pinched or cut

Retainer nut

Improper machining or casting

Guide mechanism damaged

Plugged or damaged sensing line

Other

Improper assembly installed for degree of hazard

Shutoff valve(s) will not close positively

Test cocks missing from assembly

Improper (unapproved) installation

Vertical installation

Assembly replaced

Assembly no longer required

Could not test (explain below)

Other

(8)

Westbank First Nation Backflow Assembly Test Report

Date:__________________

mm dd yyyy

Name of Premise: _ Service Address: _____________

Location of Assembly: _______ Services: Premise / Area/Zone / Fixture:

Identification: ____ / /_ / ________ / _

Type Manufacturer Model Serial Number Size

Inspection of Approved Air Gap: Inches: ___________ Pass Fail Dual Check Installed Yes (Provide SN# above)

Reduced Pressure Backflow Assembly Apparent Pressure Drop____ PSID Line Pressure Test: _ PSIG

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Initial Test

Double Check Valve Assembly Pressure Vacuum Breaker / Spill Resistant

Test After Repair

Reduced Pressure Backflow Assembly Apparent Pressure Drop ___________ PSID

Test After Repair

I certify that I have tested the above assembly in conformance with the procedures outlined in the AWWA Canadian Cross Connection Control Manual

Testers Signature: ____________ Owner / Rep. Signature: _ Shutoff valves returned to original position.

Note:___________________________________________________________________________________________________________________________________________

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass ____ PSID _ PSID ______ PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Check Valve #1 Check Valve #2 Assembly Closed Tight Closed Tight (circle)

Pass PSID PSID Fail

Air Inlet Valve Check Valve Assembly Opening Point Pressure Drop (circle)

O/F Pass

PSID PSID Fail

Differential Relief Valve Check Valve # 2 Static Pressure Drop Buffer Assembly

Opening Point Closed Tight Check Valve #1 (circle)

Pass PSID PSID _ PSID Fail

Backflow Preventer Information

New Install

Annual Test

Removed

Serial # __________________

Replaced

Serial # __________________

Unprotected Bypass

Bypass w/ Parallel BFP’s Tester Information Name:

___________________________

Cert #: _____________________

Phone #: ___________________

Gauge Calibration: ___________

M D Y

Business Name:

___________________________

[email protected] Ph: (250) 707-3332 Fax: (250) 707-3339

Kevin Rahn 1827

2506814471

06 / 28 / 2021

Troy Life & Fire Safety

3.2 ■ 9.4 6.2 ■

40203T2 203536 1/2"

■

9.0 50

■

10 / 14 / 2021

Hub Centre North Bldg F 2121 Louie Drive, West Kelowna, BC, V

Mechanical room ■ Boiler makeup

RPBA Conbraco

(9)

Causes for Operation Failure

Check relevant boxes and explanation in the remarks section. Remarks (please PRINT clearly)

__________________________________________________________________

Installation or Other Irregularities

Remarks (please PRINT clearly)

__________________________________________________________________

Foreign matter introduced during construction

Sand or grit inherent to the supply system

Debris introduced fouling or damaging seats

Air entrapment

Tuberculation or rust

Abnormal rubber disc wear or cuts

Loss of interior coating

Disc retainer fractured or worn

Springs weak or broken

O-rings pinched or cut

Retainer nut

Improper machining or casting

Guide mechanism damaged

Plugged or damaged sensing line

Other

Improper assembly installed for degree of hazard

Shutoff valve(s) will not close positively

Test cocks missing from assembly

Improper (unapproved) installation

Vertical installation

Assembly replaced

Assembly no longer required

Could not test (explain below)

Other

(10)

Deficiencies - Domestic RPBA

None

Deficiencies - Boiler make up RPBA

None

Deficiencies - Irrigation

None

Deficiencies - Irrigation

None

Deficiencies - Domestic Supply

None

Deficiencies - Boiler Makeup

None

Page 1 of 2

Report of Inspection/Test

2021-10-15 Property

Hub Centre North Bldg F 2121 Louie Drive West Kelowna BC V Print Date: 2021-10-18

Conducted by: Kevin Rahn Troy Life & Fire Safety Ltd.

#3, 2250 Leckie Road Kelowna BC V1X 7K1 (250) 860-3991

(11)

Inspector Signature

I state that the information on this form is correct at the time and place of my inspection, and all equipment tested at this time was left in operational condition upon completion of this inspection except as noted.

Inspector Name Signature Date Completed

Kevin Rahn 2021-10-15

Page 2 of 2

Report of Inspection/Test

2021-10-15 Property

Hub Centre North Bldg F 2121 Louie Drive West Kelowna BC V Print Date: 2021-10-18

Conducted by: Kevin Rahn Troy Life & Fire Safety Ltd.

#3, 2250 Leckie Road Kelowna BC V1X 7K1 (250) 860-3991

KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

Name of Premise: Contact: .

Service Address: Postal Code: .

Owners Address: Postal Code: .

Assembly: .

Manufacturer Model # Serial # Type Size

Assembly being tested: New Replacement Annually Line Pressure at time of testing: psi

Reduced Pressure Assemblies Pressure Vacuum Breaker

Double Check Assemblies Air Inlet Check Valve

1

Check 2

Check Relief V Buffer Open at

(A) (B) (A-B=C) psid psid

D-C Closed Tight Close Tight

R-P Pres. Drop ______ psid. _____ psid _____ psid did not open

Initial Confirmation Test

Passed Passed opened fully Leaked

Test Yes No Yes No

Leaked Leaked Failed Failed

D-C Closed Tight D-C Closed Tight Opened at Opened at

Test psid psid Opened at Pressure drop

After R-P pres. Drop psid

Repair Confirmation Test psid psid

Yes No Yes No Passed Passed

Air Gap Inspection: required minimum air gap separation provided? YES NO

I __________________certify this report true. Signed: Date ___ d ___ m ___ y Certificate # __________ Water Purveyor __________________________ Water service restored? YES NO Business Address: _____________________________________________Postal Code ___________ Ph. ________________

Location of Backflow Preventer ___________________________ Serves __________________________________

Email Test Report To: [email protected] Address: City Of Kelowna, 951 Raymer Ave, Kelowna, BC V1Y 4Z7 West Kelowna

Kevin Rahn

163883 RP40

Apollo

V 2121 Louie Drive, West Kelowna, BC

Hub Centre North Bldg F

2"

RPBA

Mechanical room

(250) 860-3991 V1X 7K1

#3, 2250 Leckie Road, Kelowna, BC

KELOWNA BACKFLOW PREVENTION ASSEMBLY TEST REPORT

Name of Premise: Contact: .

Service Address: Postal Code: .

Owners Address: Postal Code: .

Assembly: .

Manufacturer Model # Serial # Type Size

Assembly being tested: New Replacement Annually Line Pressure at time of testing: psi

Reduced Pressure Assemblies Pressure Vacuum Breaker

Double Check Assemblies Air Inlet Check Valve

1

Check 2

Check Relief V Buffer Open at

(A) (B) (A-B=C) psid psid

D-C Closed Tight Close Tight

R-P Pres. Drop ______ psid. _____ psid _____ psid did not open

Initial Confirmation Test

Passed Passed opened fully Leaked

Test Yes No Yes No

Leaked Leaked Failed Failed

D-C Closed Tight D-C Closed Tight Opened at Opened at

Test psid psid Opened at Pressure drop

After R-P pres. Drop psid

Repair Confirmation Test psid psid

Yes No Yes No Passed Passed

Air Gap Inspection: required minimum air gap separation provided? YES NO

I __________________certify this report true. Signed: Date ___ d ___ m ___ y Certificate # __________ Water Purveyor __________________________ Water service restored? YES NO Business Address: _____________________________________________Postal Code ___________ Ph. ________________

Location of Backflow Preventer ___________________________ Serves __________________________________

Email Test Report To: [email protected] Address: City Of Kelowna, 951 Raymer Ave, Kelowna, BC V1Y 4Z7 West Kelowna

Kevin Rahn

203536 40203T2

Conbraco

V 2121 Louie Drive, West Kelowna, BC

Hub Centre North Bldg F

1/2"

RPBA

Mechanical room

(250) 860-3991 V1X 7K1

#3, 2250 Leckie Road, Kelowna, BC

Backflow Prevention Assembly Test Report

Name of Premise: Contact:

Service Address: Service Postal Code:

R-P Pres. Drop ____ psid. _ psid ___ psid did not open

I ________________certify this report true. Signed: Date _ d _ m _ y Certificate # Water Purveyor Water service restored? YES NO Business Address: _______________________Postal Code _ Ph. ____________

Location of Backflow Preventer _ Serves ________

R-P Pres. Drop ____ psid. _ psid ___ psid did not open

I ________________certify this report true. Signed: Date _ d _ m _ y Certificate # Water Purveyor Water service restored? YES NO Business Address: _______________________Postal Code _ Ph. ____________

Location of Backflow Preventer _ Serves ________

R-P pres. Drop psid. _ psid ___ psid did not open

Name of Premise: _ Service Address: _____________

Location of Assembly: _______ Services: Premise / Area/Zone / Fixture:

Identification: ____ / /_ / ________ / _

Reduced Pressure Backflow Assembly Apparent Pressure Drop____ PSID Line Pressure Test: _ PSIG

Testers Signature: ____________ Owner / Rep. Signature: _ Shutoff valves returned to original position.

Pass ____ PSID _ PSID ______ PSID Fail

Pass PSID PSID Fail

PSID PSID Fail

Pass PSID PSID Fail

PSID PSID Fail

Pass PSID PSID _ PSID Fail