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V PREVENTION DEVICE TES1BACKFL EPORT <br />SERVICE ADDRESS CITY <br />LOCATION OF DEVICE ■ ■L. , <br />c'TYPE:SIZE <br /> MODEL NO. DOUBLE CHECK <br />REDUCED PRESSURE <br />PRES. VACUUM BREAKER Q <br />e ' ’ 2 . ’ /C- /REPORT OF TEST RESULTS <br />Reduced Pressure Principle Assembly <br />Double Check Valve Assembly <br />#2#1 <br />PSIPSI <br />a 1. CLOSED TIGHT OPENED AT PSID <br />oa2. LEAKED DID NOT OPEN <br />O CLEANED . 1/ <br />PSI_PSI DIFF. PRESS. DIFF PRESS.. <br />OPENED AT PSID AIR INLET PSIDPSIDRP <br />U REDUCED PRESSURE CHECK VALVE PSIDCLOSED TIGHTCLOSED TIGHT <br />DATE.CERTIFIED TESTER NO. INITIAL TEST BY <br /> CERTIFIED TESTER NO.. DATE.FINAL TEST BY. <br />COMMENTS: <br />THE ABOVE REPORT <br />IS CERTIFIED TO BE TRUE <br />(jom/ne/'cia/' - Sf/uAist/'/al - <br />(209) 334-9693 DATE SIGNATURE. <br />Rick Wahl, Owner <br />License #632919 <br />CHECK VALVE <br />HELD AT__ <br />LEAKED <br />INI­ <br />TIAL <br />TEST <br />FINAL <br />TEST <br />R <br />E <br />P <br />A <br />I <br />R <br />S <br />CLEANED <br />REPLACED: <br />DISC <br />SPRING <br />GUIDE <br />PIN RETAINER <br />HINGE PIN <br />SEAT <br />DIAPHRAGM <br />OTHER, DESCRIBE <br />CHECK <br />VALVE <br />DIFF. PRESS----- <br />CHECK <br />VALVE <br />DIFF. PRESS. <br />CLEANED <br />REPLACED: <br />DISC <br />SPRING <br />GUIDE <br />PIN RETAINER <br />HINGE PIN <br />SEAT <br />DIAPHRAGM <br />OTHER, DESCRIBE <br />O <br /> <br />D <br /> <br /> <br /> <br /> <br />CLEAN SENSING LINE(S) <br />REPLACED: <br />DISC: <br />UPPER <br />LOWER <br />SPRING <br />DIAPHRAGM: <br />LARGE: <br />UPPER <br />LOWER <br />SMALL <br />SEAT: <br />UPPER <br />LOWER <br />SPACER: <br />LOWER <br />OTHER, DESCRIBE <br />DIFFERENTIAL <br />PRESSURE RELIEF <br />VALVE <br />CLEANED <br />REPLACED: <br />AIR INLET <br />DISC <br />CHECK DISC <br />AIR INLET <br />SPRING <br />CHECK SPRING <br />OTHER, DESCRIBE <br />PRESSURE VACUUM <br />BREAKER <br /> <br />a <br /> <br />a <br />o <br /> <br /> <br />PSID <br />CUSTOMER: <br />} <br />MFR. <br />PSID <br />/ /Z 7/ / / z4- * . <br />.- .. /■>, -r l. . <br />PHONE NO. - - -''J <br />z.7-7.7 <br />AIR INLET Z r <br />OPENED AT ■’7 <br />DID NOT OPEN <br />• Backflow Certification & Inste nation <br />• Sewer & Drain Replaced & Repaired <br />• Water Heaters • Bathtubs <br />• Toilet & Faucet Repair <br />• Disposal Installation & Repair <br />1. CLOSED TIGHT <br />RP PSID <br />2. LEAKED <br />DEVICE INFORMATION <br />MCD it.. i. <br />SERIAL NO.