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AM Backflow Prevention .Services <br />ASSEMBLY.INFORMATION <br />TYpE: <br />slz,e: � NTFCa; <br />r t , 040 Nadorrirr Rd <br />LrQ0IfW10l <br />� � �" <br />Stockhm, CA 95225 <br />MODEL: <br />SERIAL 4: 7 <br />Offlcw: 871-22&.x.90 fax: 2D9.931-11&9 <br />Er #: <br />71NG� RT <br />Lrr. JYJgS�sT�sO Leif: -d04 -i455 Ca��: 450-690-6095 <br />C! REPXI <br />-o OL S <br />C REPLACEhAUIlT-► OLD SERIAL a: <br />E-MAIL: aaaba Jovsll�opmwxt.n&t <br />F. NEWS PLUhADING PER hAIi M. <br />TYPE OF SERVICE: r: DOMFSTCC r IFIRIGATION n FIRE M EIYPA55 <br />Wm*r Purveyor Melmit <br />SERVICE ADDRESS <br />h L/� <br />�4 "'- <br />BU51FkE95F}AiV1E5: <br />SITE PHONE; <br />Pu � I I <br />SITE ADDRESS: <br />CITY: <br />ASSEMBLY LOCATI ON: <br />poaum frrw4 WMfturkil <br />IPwf wa drenanilom A rofurdem- Lat Arws, Prop y Lbws. Curb, mWor apermsm <br />y <br />INTEfINALDEVICE 0. <br />HIM pravW4 kdrrkn daKffpcbln uch rn M1iTw dl room unit room Md wake tMInmw. mumnl{p, irdltar, EI0GENCO, Md Pwffl R8[ M. <br />OWN S#f MANAGEMF NT ADr)R S <br />OWNE)VIIAOiNAGAMENT: <br />E-MAIL ADDRESS; <br />MAIUNGADT]RESS' <br />OFFICENUMEL - <br />CITY, STATI& PIP: <br />PAX NUMIBER: <br />DOWLECIiEXVALVE , AMBOr TEST RESULTS INFORMATION <br />REDUCED PRESSURE PRIAIC7PJLE ASSEMStY <br />PRESSURE VACUUM BREAKER <br />CHECK VALVE <br />CHECK VALVE <br />DWPEREN'CIAL <br />AIR INLET VALVE <br />C4iECK VALVE <br />NO, I <br />No. 2 <br />RfUEF VALVE <br />lNfTW <br />HELD AT: —1 .- p <br />HELD AT: <br />OPENED AT; {r <br />OPENEDAT: <br />HELD AT. _ <br />Fr <br />pml) <br />p5m <br />Plat <br />MD <br />MID <br />LEAKED {] <br />CLOSED TIGHT(RP1 <br />OPEN UNDER 20PUG 0 <br />OPEN ED U NO ER 1,0 P540 Ei <br />LEAKED ❑ <br />LEAKED ❑ <br />DID NOT OPEN 0 <br />DID NOT OPEN ❑ <br />iJ ❑ CLEANED <br />i} ❑ {LEANED <br />i) ❑ CLEARED <br />i) ❑ GLEANED <br />1} ❑ CLEANED <br />R <br />REPLACED- <br />REPLACED: <br />REPJACEO: <br />REPLACED. <br />REPLACED: <br />E <br />2] rJ DISC <br />E} n DIS[ <br />2) 0 DJ5C151 <br />31 0 Da <br />2} D DISC <br />P <br />Sj m$PRING <br />3} n$pRNVG <br />S) rls"mG <br />31 r] DIAPHRAGM <br />31 13 MODULE <br />A <br />4) ❑GUJDE <br />41 ❑GUIDE <br />4) ❑DIAPHAAGMJS} <br />41 ❑FLOAT <br />41, OOTMER: <br />1 <br />5) nSEAT <br />51 n51;AT <br />$} nSEAT{51 <br />s) ncrtHm- <br />R <br />5) ONIODULE <br />61 nlp1ODULE <br />S) 11-RINGISI <br />7) 0&RINGIS) <br />T) 00-R1NG{S) <br />7) ❑MODULE <br />is OQTHEti= <br />I J# 00THER: <br />al 00THEi; <br />77:57 <br />AFTER <br />HELD AT: . <br />HL LI) AT: <br />OPENED AT; <br />OPENJ:D AT; <br />HELD AT: <br />REPAIR <br />PRD <br />x516 <br />PN* <br />p5.11 <br />CLJDSED TIGHT RP ❑ <br />P4ia <br />INITMAL ItST <br />D AFTER REPAIR <br />fis <br />H4 <br />COMMENTS: <br />SfAki TIME! <br />57AkT 7'IINE:— <br />PROPERLNSTALLATION <br />k <br />R -V fxfitCISED <br />ENO TIME, <br />MD TIME! <br />BEFORE TEST <br />x� <br />DAq-. 2q ,- <br />DATE <br />S.O.V CLOSED <br />_ 1_ <br />PASSED FAILED ❑ <br />PASSED ❑ FAILED ❑ <br />ON AIRFWA4L <br />k <br />SERVILE RESTORED <br />A <br />L T <br />V <br />- <br />TAG JI: <br />TAG N. <br />MEIER READING= <br />IAMR kFA01IM-, <br />LINE PRk551JRE:� <br />JNITIAL Tf STER <br />TESTERNAME: Jordan Leo <br />TFSTF R AFTER REPAIR <br />TWERNAME: <br />CERTIFICATIOFI sr: 16194 <br />CERTIFICATION At: <br />TEST KIT SERIAt p; 04 15 14 40 <br />TEST 1CFF SERIAL AI: <br />CUSTOMER NAME: -- <br />CALIQftATIONDATE.1 101202 5 <br />CALIBRATION DATE. <br />S ICs NAT U Rf: <br />SIGNATURE: <br />CUnMER 31GNIATURE: <br />