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BACKFLOW PREVENTION DEVICE TEST REPORT <br /> SERVICE ADDRESS METER NO CITY <br /> LOCATION OF DEVICE <br /> CUSTOMER <br /> DEVICE INFORMATION <br /> TYPE <br /> DOUBLE CHECK SIZE MFR <br /> REDUCED PRESSURE Q <br /> PHONE NO. PRES VACUUM BREAKER C MODEL NO. SERIAL NO. <br /> REPORT OF TEST RESULTS <br /> REDUCED PRESSURE DEVICES PRESSURE VACUUM BREAKER <br /> DOUBLE CHECK DEVICES RELIEF AIR INLET CHECK VALVE <br /> 1st CHECK 2nd CHECK VALVE OPENED AT <br /> CLOSED <br /> psi TIGHT ❑ <br /> INITIAL DCCLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT DID NOT <br /> TEST RP' psid LEAKED psid OPEN ❑ LEAKED ❑ <br /> LEAKED ❑ <br /> e <br /> REPAIRS <br /> AND <br /> MATERIALS <br /> USED <br /> TEST DC* CLOSED TIGHT ❑ CLOSED TIGHT tij' OPENED AT OPENED AT CLOSED TIGHT ❑ <br /> AFTER RP' psid psid psi <br /> REPAIR <br /> INITIAL TEST BY CERTIFIED TESTER NO DATE <br /> FINAL TEST BY CERTIFIED TESTER NO DATE <br /> COMMENTS: <br /> BILL HROVAT <br /> CERTIFIED BACKFLOW THE ABOVE REPORT IS <br /> PREVENTION DEVICE TESTER <br /> #1165 CERTIFIED TO BE TRUE <br /> OFFICE (209)334-4640 <br /> CELL(209)327-3971 <br /> FAX(209)367-1914 <br /> Lodi,California <br /> SIGNATURE _. __— DATE <br /> ALL TYPES-ANY LOCATION <br />