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HAMPTON'S BACKFLOW SERVICES <br /> BACKFLOW PREVENTION DEVICE TEST REPORT <br /> WILKINS 975 XL I 1 2430689 <br /> MAKE MODEL I SIZE SERIAL NUMBER ID NUMBER <br /> Assembly location: Inside the sewage treatment plant on the west side of the park. (hose bib) <br /> ❑Temporary ® Permanent ❑New, old SIN Pressure PSI <br /> Billing Country Squire Mobil Estates Device Country Squire Mobil Estates <br /> Address: 3611 Pleasant Knoll Dr. Address: 4350 Cherokee Rd. <br /> Phone# San Jose,CA 95148 Stockton,CA 95215 <br /> Test method, ® RP ❑ SVB <br /> REDUCED PRESSURE PRINCIPAL ASSEMBLY ❑ DC ❑ DCDA <br /> 9tb Edition ❑ PVI3 ❑ RPDA <br /> USC DOUBLE CHECK VALVE ASSEMBLY <br /> Cheek Valve#1 Check Valve#2 Relief Valve PVB / SVB <br /> Air Inlet opened at Did <br /> INITIAL Held at q-V PSID Held at PSID i Opened at 3. 0 PSID ❑„ol <br /> TEST PSID open <br /> Closed Tight Check Valve held at <br /> ❑ Leaked Leaked ❑ Did Not Open <br /> PSID <br /> ❑ Cleaned ❑ Cleaned ❑ Cleaned ❑ Clean <br /> REPAIRS ❑ Replaced ❑ Replaced ❑ Replaced ❑ Replace <br /> ❑ Disc ❑ Disc ❑ Disc ❑ O-Ring <br /> ❑ Disc Bolder ❑ Disc Holder <br /> ❑ Disc Holder ❑ Air Inlet Disc <br /> ❑ Spring ❑ Spring ❑ Spring p g ❑ Air Inlet Spring <br /> ❑ O-ring ❑ 0-rin <br /> g ❑ O-ring El Check Disc <br /> Module <br /> ❑ ❑ Module ❑ Diaphragm El Disc holder <br /> ❑ Other ❑ Other ❑ Bellows ❑ Check Spring <br /> ❑ Other ❑ Other <br /> FINAL Held at PSID Held at PSID Opened at PSID Air Inlet PSID <br /> TEST <br /> Closed Tight[] (RP) Check Valve PSID <br /> Comments: <br /> INITIAL Date: Certified Tester No. <br /> TEST (mdy) 6073 <br /> - 0, Passed ❑ Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> Date: CeAlified Tester No. <br /> REPAIRS (mdy) 6073 <br /> Repair By: Print Name: <br /> KEN HAMPTON <br /> FINAL Date: Certified Tester No. <br /> TEST (mdy) 6073 <br /> Passed ❑ Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> HAMPTON'S BACKFLOW SERVICES Authorized By: <br /> (209) 572-6782 <br />