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BACKFLOW PREVENTION DEVICE TEST REPORT <br /> SERVICE ADDRESS --METER NO CITY <br /> N <br /> LOCATION OF DEVICE �J-P � �tJ ob Ac-�_x, zz � <br /> 6dTOM ERG.cm-a<-� DEVICE INFORMATION <br /> #—k TYPE <br /> ` I y <br /> Z ZVIGh LG}►� DOUBLE CHECK ❑ SIZE. f MFR <br /> Y' 2 yL7 REDUCED PRESSURE <br /> Vr— <br /> PHONE NO. FIRES VACUUM BREAKER ❑ MODEL NO. SERIAL NO. S� <br /> josq� �Y <br /> REPORT OF TEST RESULTS <br /> REDUCED PRESSURE DEVICES PRESSURE VACUUM BREAKER <br /> DOUBLE CHECK DEVICES RELIEF AIR INLET CHECK VALVE <br /> VALVE <br /> 1st CHECK 2nd CHECK OPENED AT CLOSED <br /> psi TIGHT ❑ <br /> INITIAL DC * CLOSED TIGHT CLOSED TIGHT OPENED AT DID NOT <br /> TEST RP * psid LEAKED ❑ psid OPEN ❑ LEAKED ❑ <br /> LEAKED ❑ <br /> REPAIRS <br /> AND <br /> MATERIALS <br /> USED <br /> TEST DC ' CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT OPENED AT CLOSED TIGHT ❑ <br /> AFTER RP * psid psid psi <br /> REPAIR <br /> INITIAL TEST BY 13i /I P/ CERTIFIED TESTER NO �' �S 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 f <br /> Lodi,California SIGNATURE �.��'1/�1. DATE <br /> ALL TYPES-ANY LOCATION <br />