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HAMPTON'S BACKFLOW SERVICES <br /> BACKFLOW PREVENTION DEVICE TEST REPORT <br /> WILKINS 975 3 <br /> MAKE MODEL B04027 <br /> Assembly location: To the rear of the school, approxi ately centered, next to wthe wSE , mater tank, <br /> Jte BID NUMBER <br /> ❑Temporary Permanent <br /> Billing ❑New, old WN <br /> g Ripon Unified School District <br /> Address: 304 North Acacia Ave. Device Colony Oak School <br /> Ripon,CA 95366 Address: 22241 S.Murphy Rd. <br /> Phone# 209 599-2131 Ripon,CA 95366 <br /> Test method, <br /> PRINCIPAL ASSEMBLY ® RP S VB <br /> REDUCED PRESSURE PR <br /> 9th Edition ❑ DC ❑ DCDA <br /> USC DOUBLE CHECK VALVE ASSEMBLY ❑ PVB ❑RPDA <br /> Check Valve#1 Check Valve#2 <br /> Relief Valve pVB / SVB <br /> INITIAL Held at-PSID Held at Air Inlet opened at Did <br /> TEST PSID Opened at 2. 3 PSID <br /> ❑not <br /> Closed Tight PSID open <br /> ❑ LeakedCheck Valve held at <br /> Leaked [I Did Not Open <br /> PSID <br /> ElCleaned Cleaned <br /> REPAIRS El Replaced ❑ Cleaned ❑ Clean <br /> ❑ Replaced ❑ Replaced <br /> ❑ Disc ❑ Disc ❑ Replace <br /> ❑ Disc Holder ❑ Disc ❑ O-Rin <br /> ❑ Disc Holder g <br /> ❑ <br /> Spring El Bolder <br /> p g ❑ Spring ❑ Air Inlet Disc <br /> ❑ O-ring ❑ Spring <br /> ❑ O-ring El Air Inlet Spring <br /> ❑ Module ❑ O-ring <br /> ❑ Module ❑ Check Disc <br /> ❑ Other El <br /> ❑ Diaphragm ❑ Check Spring <br /> ❑ Bellows ❑ Other <br /> ❑ Other <br /> FINAL Held at PSID Held at _ PSID Opened at PSID <br /> TEST Air Inlet_PSID <br /> Closed Tight El IRP) Check Valve_PSID <br /> Comments: <br /> INITIAL Date: Certified Tester No. <br /> TEST (only) 1 6073 <br /> © Passed Failed <br /> Test By: I Print Name: <br /> l KEN <br /> Date: C ified Tester No. HAMPTON <br /> REPAIRS (only) 6073 <br /> Repair By: Print Name: <br /> KEN HAMPTON <br /> FINAL Date: Certified Tester No. <br /> TEST (mdy) 6073 <br /> Passed Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> HAMPTON'S BACKFLOW SERVICES Authorized By: <br /> (209) 572-6782 <br />