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r <br /> r, I <br /> BACKFLOW ASSEMBLY TEST REPORT <br /> t <br /> a12 MODEL SERIAL NO. 2D NO. � <br /> Location: _,I- , f1(/�1 _ <br /> KJ+•*�L 1 <br /> jTemporary /Permanent New, ,told SIN /97Y <br /> Owner/Mgr Device 11 <br /> Address: Address: <br /> a I <br /> Phone#f ) Site Phone#{ ) <br /> Rater Purveyorry /I� I' SVB <br /> CYUwt `-` REDUCED pRESSURE PRINCIPLE ASSEMBLY DC , DCDA <br /> I <br /> DOUBLE CHECK,VALVE ASSEMBLY <br /> Check Valve#1 Check Valve#2 Relief Valve PVBISVB <br /> I 4�_ <br /> . <br /> Held Held at_--__--- I'SID Opened at �:-�1t'SICI Air Inlet Opened , <br /> at PSID At PSI) <br /> Did Not Open- Did Not Open <br /> f beakedClosed Tight Check Valve held <br /> �' Leaked At PSID <br /> { Cleaned Cleaned 1:3 Cleaned I_1 Cleaned <br /> Replaced Replaced IC Replaced �; Replaced <br /> REPAIRS L Disc C Disc L Disc 0-ring <br /> ,I Disc Holder ❑ Disc Holder Disc Holder Air Inlet Disc <br /> t Spring J Sprung L7 Spring n Air Inlet Spring <br /> U I O-ring 0-ring O-ring(s) L Check Disc <br /> Module TJ— Module Module Disc Holder <br /> Other Other ❑ Diaphragm(s) Check Spring <br /> Li Other Other <br /> i <br /> FINAL,LEST, Held at Heid at PSID Opened at PSID Air Inlet -_-_ PSID <br /> PSID <br /> -yClosed'fight ::(RP) Check Valve PsID <br /> Comments: <br /> I <br /> Date Time Tester Nasse # Signature Passed j Failed <br /> Initial <br /> Lest �� g� wve2yJ /494e l `� <br /> I <br /> t <br /> Repairs <br /> I I I <br /> Final <br /> Test kH <br /> STI;AD BACKFLOW PRE"vT NTION SERVICES,INC. r:T 4555 N.PERSHING AVE.,333.141,STOCKFON,CA 95207-6-140 C <br /> Gary Anu-ine AWWA Cert-#8655 n Betty Amrine AW"WA Cert.;1061,A11'W'A Specialist Cert-#219 n Contr.Lic.#&48490 <br /> Gary Cel.: 209-$I5-1826 z5 FAX&PFL- 800-640-5172 FAX-'209-333-0643 a Betty Cel.: 800-910-6898 <br /> i, is <br /> l ' <br />