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VA LESS MANUFACTURING, INC. <br />Contractor Customer <br />DIALYSIS NORTH <br />Date Location Product <br />7Z�'Dy lSU/ U-,qc/G loAje- RJ. /&o.J, cif-, Qj <br />Technician <br />Submersible Pump Identification <br />Manufacturer Model No. Serial Number <br />f?e-0Z'ACKEr-- P/ 5D i 15®23rr95/ 1369 <br />Leak Detector Identification <br />Manufacturer Description Other Style Leak Detector <br />Fe. Pe�i�cy �T�_iyc>� .SEA4A;L fr 030S12)9 <br />Diaphragm -type <br />Piston -type yc <br />Leak Detector in Submersible Pump <br />Test at Dispenser <br />1. Operating Pump Pressure 2 psi (Purging Test System) <br />2. Gallons per hour rate 3 (Leak Test Phase 1) <br />3. Line pressure with pump shut off / 5 psi (Leak Test Phase l) <br />4. Bleedback Test with pump off 2 -,'Y,5 -ml (Bleed -back Test) <br />5. Step -through time to full flow `/7 seconds (Step -through Time) <br />6. Leak detector stays in leak search position. (Leak Test Phase 2) Yes >(° No <br />LEAK DETECTOR TEST <br />Note: Pass = Leak detector stays in slow -flow during GPH test <br />Fail = Leak detector steps through to allow full pump pressure during GPH test <br />Fail <br />*Complete thermal expansion test before failing leak detector. <br />Form 890C (May 9, 2002) <br />2002 Vaporless Manufacturing, Inc., Prescott Valley, AZ DIALYSIS NORTH <br />P.O. Box 95 <br />Bella Vista, CA 96008 <br />(530) 275-6667 <br />