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BACKFLOW PREVENTION DEVICE TEST REPORT <br /> SERVICE ADDRESS ��_ _ �`'���+'� ----------METER NO CITY�� <br /> LOCATION OF DEVICE -� ' <br /> CST MER DEVICE INFORMATION <br /> tt (� TYPE <br /> � El <br /> DOUBLE CHECK ❑ SIZE. MFR <br /> <" (}t-tol <br /> REDUCED PRESSURE El- <br /> PHONE NO. • PRES VACUUM BREAKER 1.3 MODEL NO- � SERIAL NO. a <br /> __+{O <br /> REPORT OF TEST RESULTS <br /> REDUCED PRESSURE DEVICES PRESSURE VACUUM BREAKER <br /> DOUBLE CHECK DEVICES RELIEF AIR INLET CHECK VALVE <br /> VALVE OPENED AT CLOSED <br /> 1st CHECK 2nd CHECK <br /> psi TIGHT ❑ <br /> INITIAL <br /> DC * CLOSED TIGH CLOSED TIGHT P4 OPENED AT DID NOT <br /> �,[� <br /> TEST RP*_� psid LEAKED ❑ psid OPEN la 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 /> CERTIFIED TESTER NO.. ���� - DATE <br /> INITIAL TEST BY <br /> FINAL TEST BY CERTIFIED TESTER NO. DATE <br /> COMMENTS-. <br /> CERD BACKFLOW "_ °THE fflk"V]E;,l Rt,_r <br /> PREVENTION DEVICE TESTER <br /> #1165 - CERTIFIED TO BE TRUE <br /> OFFICE (209)3344640 <br /> CELL(209)327-3971 <br /> FAX 209)367-1914 <br /> ( � ' DATE _2 I <br /> r <br /> Lodi,Califomia <br /> SIGNATUREf s .1 <br /> ALL TYRES-ANY LOCATION <br />