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HAMPTON'S BACKFLOW SERVICES <br /> BACKFLOW PREVENTION DEVICE TEST REPORT <br /> WILKINS 975 XL 17 2430689 <br /> MAKE MODEL SIZE I SERIAL NUMBER ID NUMBER <br /> Assembly location: Inside the sewage treatment plant on the west side of the park. (hose bib) <br /> ❑Temporary I ® 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 /> San Jose,CA 95148 Stockton,CA 95215 <br /> Phone# <br /> Test method, ® RP ❑ SVB <br /> REDUCED PRESSURE PRINCIPAL ASSEMBLY ❑ DC ❑ DCDA <br /> 9th Edition ❑ PVB ❑RPDA <br /> USC DOUBLE CHECK VALVE ASSEMBLY <br /> Check Valve#1 Check Valve#2 Relief Valve PVB / SVB <br /> Air Inlet opened at Did <br /> INITIAL Held at PSID Held at PSID Opened at 3, 2, PSID ❑not <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 Holder ❑ Disc Holder ❑ Disc Holder ❑ Air Inlet Disc <br /> ❑ Spring ❑ Spring ❑ Spring ❑ Air Inlet Spring <br /> ❑ O-ring ❑ O-ring ❑ O-ring ❑ Check Disc <br /> ❑ Module ❑ Module ❑ Diaphragm ❑ Disc holder <br /> ❑ Other ❑ Other ❑ Bellows ❑ Check Spring <br /> ❑ Other ❑ Other <br /> FINAL Held at PSID Meld 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 passed ❑ Failed <br /> .13 Lo I <br /> Test By: Print Name: <br /> �<gAa�� KEN HAMPTON <br /> Date: Ce ifted Tester No. <br /> REPAIRS (mdy) 6073 <br /> Repair By: Print Name: <br /> KEN HAMPTON <br /> FINAL Date: Certified Tester No. <br /> TEST (mdy) 6073 ❑ Passed ❑ Failed <br /> Test By: Print Name: <br /> KEN HAMPTON <br /> HAMPTON'S BACKFLOW SERVICES Authorized By: <br /> (209) 572-6782 <br />