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' `•Sir' - ,i <br /> i <br /> JC3ACKFLOW ASSEMBLYTEST REPORT � <br /> SrZE NL1ItE <br /> MODEL 5ERIAL NO. ID NO. <br /> Location: � � <br /> Temporary :.Permanent _ New old SN <br /> i <br /> Owner/Mgr _ _ Device <br /> I <br /> Address __ _ Address: <br /> Phone#( ) Site Phone#( ) { <br /> i <br /> Water Purveyor p SVS <br /> C1 , <br /> REDUCED PRESSURE PRINCIPLE ASSEMBLY DC :."PDA <br /> i <br /> DOUBLE CHECK VALVE ASSEMBLY <br /> Check Valve#1 Check Valve#2 Relief Valve PVB/SVB <br /> Held Held at !?SID Opened at PSID Air Inlet opened <br /> at 1'SID At PSID <br /> LClosed Tight Did Not Open Did Not Open <br /> Leaked Check Valve held <br /> Leaked At PSTD <br /> Cleaned Cleaned n Cleaned Cleaned <br /> r Replaced Replaced +_l Replaced D Replaced <br /> REPAIRS <br /> Disci isc f i Disc ❑ O-ring <br /> Disc Holder Disc Holder ! Dise Holder Air Inlet Disc <br /> Spring ❑ Spring Spring Air Inlet Spring <br /> Z I O-ring 2-10-ring i._,.f 0-ring(s). Check-Dice i <br /> Module ❑ Module Module .Disc Holder <br /> Other Other }� '"Diaphragxir(s) J Check Sprirng <br /> I <br /> OtherOther <br /> FINAL TEST Held ax Held at P'SID Opened at ,19PSID Air Inlet-PSID <br /> PSID Closed Tight) Check Valve PsM <br /> Comments: <br /> Date Time Tester Name # Signature Passed Failed <br /> Initial <br /> Test ` � �� ���9 -1 1{.4"'140Repairs <br /> I / <br /> Z <br /> TestTt >f <br /> Test � �'�I �' ` <br /> STEAD ACKF'LOU'PREVENTION SER1,10ES,INC. 4'" N.PERSHING AVE.,333-141,STOCKTON,C.A.9"5207-6740 <br /> Gary Amrine AWWA Cert.#8653 m Betty Amrine A1L'WA Cert.#1061,AV4'W A Specialist Cert.#219 o Contr.Lie.#858490'' <br /> Gary.Cel.: 209-815-1826 m FAX&PH: 800-640-5171 FAX, 209-333-0843 n Betty Cel.: S00-910-6898 - <br />