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r � HAMPTON'S BACKFLOW SERVICES^ `� �1�yr ED <br /> BACKFLOW PREVENTION DEVICE TEST RE bk+ © 2p05 <br /> FEBCO 825Y 2 A120700 THE <br /> MAKE MODEL SIZE SERIAL NUMBER <br /> Assembly location: To the rear of the school,approximately centered,next to the water tank. ' <br /> ❑Temporary I ® Permanent I Lj New, old S/N <br /> Billing Ripon Unified School District Device Colony Oak School <br /> Address: 304 North Acacia Ave. Address: 22241 S.Murphy Rd. <br /> Ripon,CA 95366 Ripon,CA 95366 <br /> Phone 209 599-2131 <br /> Test method, ® RP ❑ SVB <br /> :REIDUCED PRESSURE PRINCIPAL ASSEMBLY ❑ DC ❑ DCDA <br /> 9th Edition ❑ PVB ❑ RPDA <br /> USC DOUBLE CCK VALVE ASSEMBLY <br /> Check Val1 Check Valve#2 Relief Valve PVB / SVB <br /> Air Inlet opened at Did <br /> INITIAL Held at_�p. � PSro Held at PSID Opened at 3. O PSID ❑ not <br /> TEST PSID open <br /> Closed Tight Check Valve held at <br /> ❑ Leaked Leaked ❑ Did Not Open <br /> PSID <br /> ❑ Cleaned El Cleaned Cleaned <br /> REPAIRS ❑ Replaced ❑ Clean <br /> P El Replaced El Replace <br /> ❑ Disc ❑ Disc ❑ Disc ❑ O-Ring <br /> ❑ Disc Holder ❑ Disc Holder ❑ Disc Holder <br /> ❑ ❑ Air Inlet Disc <br /> Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring <br /> ❑ O-ring ❑ O-ring ❑ O-ring ❑ Check Disc <br /> ❑ Module ❑ Module ❑ Diaphragm ❑ Check Spring <br /> ❑ Other ❑ Other ❑ Bellows ❑ Other <br /> ❑ Other <br /> FINAL Held at PSID Held at PSID Opened at PSID Air Inlet PSID <br /> TEST <br /> Closed Tight ❑(RP) Check Valve_PSID <br /> Comments: <br /> INITIAL Date: Certified Tester No. <br /> TEST (mdy) 6073 <br /> © Passed Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> Date: Ce ified Tester No. <br /> REPAIRS (mdy) 6073 <br /> Repair By: Print Name: <br /> KEN HAMPTON <br /> FINAL Date: Certified Tester No. <br /> TEST (mdy) 6073 paw Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> HAMPTON'S BACKFLOW SERVICES Authorized By: <br /> (209) 572-6782 <br />