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FIAMPTON'S BACKFLOW SERVICES <br /> BACKFLOW PREVENTION DEVICE TEST REPORT <br /> WILKINS 975 XL 1 2430689 <br /> MAKE MOD� 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 /> 9th Edition REDUCED PRESSURE PRINCIPAL ASSEMBLY ❑ DC ❑ DCDA <br /> USC DOUBLE CHECK VALVE ASSEMBLY ❑PVB E]RPDA <br /> Check Valve#1 Check Valve#2 Relief Valve PVB / SVB <br /> Air Inlet opened at Dia <br /> INITIAL Held at PSID Held at PSID Opened at 2. Q PSID ❑nor <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 [1 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 &A. PsrD Held at PSID Opened at3AQ PSID Air Inlet PSID <br /> TEST <br /> Closed Tight IR(RP) Check Valve PSID <br /> Comments: <br /> INITIAL Date: TCertified Tester No. <br /> TEST (:ndy) 1 () 6073 E] Passed © Failed <br /> Test By: "7 Print Name: <br /> KEN HAMPTON <br /> Date: t ` n Ce ed Tester No. <br /> REPAIRS (mdy) l (� `(a'7 ifi6073 <br /> Repair By: Print Name: <br /> KEN HAMPTON <br /> FINAL Date: Certl red Tester No. <br /> TEST (mdy) (�4 6073 Q. Passed ❑ Failed <br /> Test By: K <br /> Print Name:L.� <br /> KEN HAMPTON <br /> HAMPTON'S BACKFLOW SERVIC S Authorized By: <br /> (209) 572-6782 <br />