American Society of Sanitary Engineering s2

American Society of Sanitary Engineering

Seal (Certification) Program

Laboratory Evaluation Report Form for:

Reduced Pressure Principle Backflow Preventers and Reduced Pressure Fire Protection Principle Backflow Preventers

Tested for compliance to ASSE Standard #1013

Revised: January, 2005

Laboratory File Number

Manufacturer Model No.

Address

Serial No.

Other Identification Markings

Size

Type of device (check one): RP or RPF

Configuration for Approval:

(as defined in Section V of the Standard)

NOTE: Separate, complete laboratory evaluation report forms for each alternate orientation must be submitted to ASSE for review by the ASSE Seal Control Board.

General information and instructions for the testing engineer:

Within the text there may be items which are only advisory to conditions which experience indicates could be troublesome. It is not for evaluation related to acceptance of the product.

There may be other items for which the judgment of the test engineer will be involved. Should there be a question of compliance with that provision of the standard, a conference with the manufacturer should be arranged to enable a satisfactory solution of the question.

Should disagreement persist and compliance remain in question by the test agency, the agency shall, if the product is in compliance with all other requirements of the standard, file a complete report on the questionable items together with the test report, for evaluation by the ASSE Seal Control Board. The Seal Control Board will then review and rule on the question of compliance with the intent of the standard item involved.

Documentation of material compliance must be furnished by the manufacturer. He shall furnish to the testing agency, a bill of material which clearly identifies the material of each part included in the product construction. This identification must include any standards which relate thereto.

LABORATORY EVALUATION REPORT ASSE STANDARD 1013

Page 1 of 12 pages (2005)

Revised: 01/02/2008

Product Name Type of Device: RP or RPF

Model Number Size(s)

Date Submitted for Review Date Review Complete

Has this device been submitted for review prior to the above mentioned date? Yes No

Were the test units production models? Yes No

or prototypes? Yes No

Section I

1.0 General

1.1 Application. Does the purpose of the device agree with that of the standard? Yes

Questionable

If questionable, explain:

NOTE: This standard applies to single as well as manifolded assemblies.

1.2.1 Description. Does the device conform to the product described in the standard? Yes

Questionable

If questionable, explain:

1.2.2 Size. inches ( mm).

1.2.3 Pressure Range. What is the minimum working pressure as noted by the manufacturer?

psi ( kPa)

What is the maximum working pressure as noted by the manufacturer? psi ( kPa)

In compliance? Yes

Questionable

If questionable, explain:

NOTE: RP and RPF devices have different pressure requirements.

1.2.4 Temperature Range.

Cold Water: °F to °F( °C to °C).

Hot Water: °F to °F ( °C to °C).

1.3.2.1 Relief Valve Connections. Indicate shape of discharge port.

Can a threaded pipe, a screwed fitting or a tubing be connected internally or externally to the discharge port?

Yes

Questionable

If questionable, explain:

In compliance? Yes

Questionable

If questionable, explain:

1.3.2.2 Female Pipe Threaded Connections. In compliance? Yes

Questionable

If questionable, explain:

1.3.2.3 Repairability. In compliance? Yes

Questionable

If questionable, explain:

1.3.2.6 Test Cock Location. In compliance? Yes

Questionable

If questionable, explain:

1.3.2.7 Test Cock Size, Inlet and Outlet Connection. In compliance? Yes

Questionable

If questionable, explain:

1.3.2.9 Shut-off Valves. In compliance? Yes

Questionable

If questionable, explain:

State the manufacturer size and model number of all shut-off valves tested with the device?

Section II

2.0 Test Specimens

2.1 State the quantity of units provided for the evaluation of the orientation requested.

2.2 How many units were utilized during the laboratory evaluation?

2.3 Drawings. Were assembly drawings, installation drawings and other technical data which are needed to enable a testing agency to determine compliance with this standard submitted with the valve?

Yes

Were these drawings reviewed in the laboratory? Yes

Note: Were tests required for an additional orientation? Yes

If yes, were the required additional samples submitted for this additional orientation? Yes

NOTE: Separate, complete laboratory evaluation report forms must be submitted for each alternate orientation. The correct number of devices specified in the standard for each intended orientation must be submitted to the testing facility for evaluation to this standard.

2.5 Manifold Assembly. Is this a manifold assembly type backflow preventer? Yes

If yes, the individual devices that constitute the manifold shall be tested to each section of the standard in their intended orientation based on the pipe size for each individual device. Was this done?

Yes

Questionable

If questionable, explain:

Section III

3.0 Performance Requirements and Compliance Testing

3.1 Independence of Components

In compliance? Yes

Questionable

If questionable, explain:

3.2 Hydrostatic Test of Complete Device

What was the supply pressure at the inlet? psi ( kPa)

The test period was for minutes.

In compliance? Yes

Questionable

If questionable, explain:

3.3 Hydrostatic Test of Outlet Only

What was the pressure applied to the outlet psi ( kPa)

The test period was for minutes.

In compliance? Yes

Questionable

If questionable, explain:

3.4 Allowable Pressure Loss at Rated Flow

What was the rated flow? GPM ( L/s).

For RPF devices, use 150% of the rated flow for five (5) minutes.

What was the maximum pressure loss observed up to and including the rated flow? psi ( kPa)

In compliance? Yes

Questionable

If questionable, explain:

3.5 Drip Tightness of the Second Check Valve

What pressure was applied to the upstream side? psi ( kPa)

Indicate the initial height difference between the two (2) sight glasses. inches ( mm)

Indicate the final height difference between the two (2) sight glasses inches ( mm)

In compliance? Yes

Questionable

If questionable, explain:

3.6 Intermediate Chamber Pressure vs. Inlet Pressure at Static

What was the differential gauge reading? ______psi ( ______kPa)

In compliance? Yes

Questionable

If questionable, explain:

3.7 Relief Valve Discharge With Positive Supply Pressure

(with backflow and supply pressure at least 2 psi (13.8 kPa)

What was the supply pressure? psi ( kPa)

What was the intermediate chamber pressure? psi ( kPa)

What was the flow rate from the relief valve? GPM ( L/s)

In compliance? Yes

Questionable

If questionable, explain:

3.8 Relief Valve Discharge Test with Atmospheric Supply Pressure

(With no backflow and the supply pressure at atmospheric)

What was the supply pressure? psi ( kPa)

What was the intermediate chamber pressure? psi ( kPa)

What was the flow rate from the relief valve? GPM ( L/s)

In compliance? Yes

Questionable

If questionable, explain:

3.9 Relief Valve Opening and Inlet Check Valve Pressure Drop Test

What was the pressure differential across the first check when the relief started to open at the following supply pressures:

(a) 25 psi (172 kPa)? psi ( kPa) differential.

(b) 50 psi(344 kPa) ? psi ( kPa) differential.

(d) 100 psi (688 kPa)? psi ( kPa) differential.

(e) 125 psi (860 kPa)? psi ( kPa) differential.

(f) 150 psi (1032 kPa)? psi ( kPa) differential.

(g) 175 psi (1204 kPa.)? psi ( kPa) differential.

(h) 200 psi (1376 kPa)? psi ( kPa) differential.

Did the relief valve close tightly at each increment of pressure? Yes

In compliance? Yes

Questionable

If questionable, explain:

3.10 Back Siphonage Test

(a) Apply and hold a vacuum of 25 inches (635 mm) of mercury for five (5) minutes.

In compliance? Yes

Questionable

If questionable, explain:

(b) Gradually applied vacuum. In compliance? Yes

Questionable

If questionable, explain:

Questionable

If questionable, explain:

The maximum observed rise of the meniscus in the sight glass was inches ( mm).

What was the diameter of the fouling wire used? inches ( mm)

In compliance? Yes

Questionable

If questionable, explain:

3.11 Relief Valve Location

When the backflow of water has ceased and discharge from the relief valve discharge port has stopped, was the water level in the intermediate chamber above the lowest portion of the first check seat orifice?

Yes

In compliance? Yes

Questionable

If questionable, explain:

3.12 Relief Valve vs. Supply Pressure Fluctuation Test for RPF Devices Only

At 115 psi (793 kPa) was there any leakage from the relief valve? Yes

At 100 psi (690 kPa) was there any leakage from the relief valve? Yes

In compliance? Yes

Questionable

If questionable, explain:

3.13 Deterioration at Manufacturer's Extremes of Temperature and Pressure Ranges

Cold water assemblies tested at °F ( °C) for hours.

Hot water assemblies tested at °F ( kPa).

While still at temperature, retest to Section 3.9.

In compliance? Yes

Questionable

If questionable, explain:

Did the second check hold 1.0 psi (6.9 kPa) for an RP assembly or 0.5 psi (3.5 kPa) for an RPF assembly following the high temperature conditioning? Yes

Questionable

If questionable, explain:

After running 40.0°F (4.4°C) water through the assembly for one (1) hour retest to section 3.9?

In compliance? Yes

Questionable

If questionable, explain:

Did the second check hold 1.0 psi (6.9 kPa) for an RP assembly or 0.5 psi (3.5 kPa) for an RPF assembly following the low temperature conditioning? Yes

Questionable

If questionable, explain:

3.14 Cycle Test - Field Test

Cycle Test Field Test

3.14.2 Type RP Assemblies Only

(a) Flow water at 25% of the rated flow (see Table 1 for size and rated flow).

What was the flow rate? GPM ( L/s)

What was the supply pressure? psi ( kPa)

The test period was for seconds.

(b) What was the static pressure? psi ( kPa)

The test period was for seconds.

(d) What was the supply pressure? psi ( kPa)

The test period was for seconds.

(e) Repeat steps (a) through (d) for 1250 cycles.

After 1250 cycles, did you perform tests per Section 3.5 and Section 3.9? Yes

Were these two sections in compliance? Yes

Questionable

If questionable, explain:

(f) Flow water at 50% of the rated flow (see Table 1) for three (3) seconds.

(g) Repeat steps (b) through (e) at this flow.

After 1250 cycles, did you perform tests per Section 3.5 and Section 3.9? Yes

Were these two sections in compliance? Yes

Questionable

If questionable, explain:

(h) Flow water at 75% of the rated flow (see Table 1) for three (3) seconds.

(i) Repeat steps (b) through (e) at this flow.

After 1250 cycles, did you perform tests per Section 3.5and Section 3.9? Yes

Were these two sections in compliance? Yes

Questionable

If questionable, explain:

(j) Flow water at 100% of the rated flow for three (3) seconds.

(k) Repeat steps (b) through (e) at this flow.

After 1250 cycles, did you perform tests per Section 3.5 and Section 3.9? Yes

Were these two sections in compliance? Yes

Questionable

If questionable, explain:

3.14.3 Cycle for Type RPF Assemblies Only

(a) Flow water at 25% of the rated flow (see Table 1 for size and rated flow).

What was the flow rate? GPM ( L/s)

What was the supply pressure? psi ( kPa)

The test period was for seconds.

(b) What was the static pressure? psi ( kPa)

The test period was for seconds.

(d) What was the supply pressure? psi ( kPa)

The test period was for seconds.

(e) Fluctuate the supply pressure from 175 psi (1206 kPa) down to 100 psi (690 kPa) for 500 cycles.

(f) Repeat steps (a) through (e) ten (10) times.

After step (f), did you perform tests per Section 3.5 and Section 3.9? Yes

Were these two sections in compliance? Yes

Questionable

If questionable, explain:

3.14.6 Field Test

Follow the ANSI/ASSE Series 5000 Field Test Procedures for ASSE Standard #1013 and the requirements of Section 3.14.6 and 3.14.7 of the ASSE 1013 Standard.

3.15 Body Strength for Type RPF Assemblies Only

What was the pressure used for this test? psi ( kPa).

This test was for minutes.

Were there any leaks or indications of damage that would prevent the device from complying with any section of this standard? Yes

In compliance? Yes

Questionable

If questionable, explain:

3.16 Seat Adhesion Test for Type RPF Devices Only

Did the adhesion test meet all of the requirements of Paragraph 17 of UL 3.12? Yes

Questionable

If questionable, explain:

Section IV

4.0 Detailed Requirements

4.1 Materials

Did the manufacturer provide evidence that the materials make-up of the device has been used successfully in similar applications for at least one (1) year? Yes

4.1.1 Materials in Contact with Water

Did any solder and fluxes or metal alloys in contact with the potable water supply exceed 0.2% or 8% lead content respectively? Yes

Questionable

If questionable, explain:

4.1.2 Elastomers and Polymers.

Did all of the elastomers and polymers in contact with the water comply with the requirements of the U.S. Code of Federal Regulations (CFR) Title 21, 177.2600? Yes

Questionable

If questionable, explain:

4.1.3 Ferrous Cast Parts. In compliance? Yes

Questionable

If questionable, explain:

4.1.4 Ferrous Cast Parts in Contact with Water. In compliance? Yes

Questionable

If questionable, explain:

4.1.5 Stainless Steel Components. In compliance? Yes

Questionable

If questionable, explain:

4.1.6 Non-Ferrous Wetted Parts. In compliance? Yes

Questionable