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BACKFLOW PREVENTION DEVICE TEST REPORT <br /> SERVICE ADDRESS (/GG Z /l/ METER NO CITY /� <br /> LOCATION OF DEVICE <br /> e <br /> CUSTOMER DEVICE INFORMATION <br /> TYPE <br /> 7 T Ci++'Vt DOUBLECHECK ❑ SIZE. _--MFR 6!6510 <br /> 4�GPi J �A m/S=`YG� REDUCED PRESSURE 05r— X <br /> PHONE NO R.-J. si 7 PRES VACUUM BREAKER El MODEL NO. $1S SERIAL NO. JO174Y <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 <br /> OPENED AT CLOSED <br /> psi TIGHT ❑ <br /> INITIAL DC ' CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT DID NOT <br /> TEST RP ' psid LEAKED psid OPEN ❑ <br /> LEAKED LEAKED ❑ <br /> ' REPAIRS <br /> AND Po/o <br /> MATERIAE <br /> USED <br /> TEST DC 'CLOSED TIGHT• . CLOSED TIGHT OPENED AT OPENED AT <br /> AFTER CLOSED TIGHT o <br /> REPAIR RP '�psid 31-1/ psid psi <br /> INITIAL TEST BY 17- r"r�-- CERTIFIED TESTER NO /bS 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 /> #71CERTIFIED TO BE TRUE <br /> OFFICE (209)9)334-4640 / <br /> CELL 12091:127-3971 <br /> FAX(209)367-19167-1914 iyf��'/' <br /> Lodi,California SIGNATURE / ��`/EJ''t7 DATE <br /> ALL TYPES-ANY LOCATION <br />