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209-838-7842 <br />ASSEMBLY INFORMATION <br />NAME: <br />ADDRESS: <br />CITY.STATE.ZIP <br />.CA <br />REPORT OF TEST RESULTS <br />AIR CHECK <br />VALVEINLET□□CLOSED TIGHT CLOSED TIGHT□CLOSED TIGHTINITIAL <br />OPENED AT (PSID)HELD AT (PSID)OPENED AT (PSID)HELD AT (PSID)HELD AT (PSID) <br />OPENED UNDER 1 0 PSIDOPENED UNDER 2 0 PSID□ElO□LEAKEDLEAKEDTEST OR DID NOT OPENOR DID NOT OPEN <br />0□1. CLEANED1. CLEANED1. CLEANED□1. CLEANED <br />R <br />REPLACED:REPLACED:REPLACED:E □2. DISC2. DISC2. DISCP <br />3. SPRING3. DIAPHRAGM3. SPRING3. SPRINGA <br />4. GUIDE4. FLOAT4. GUIDE4. GUIDEI <br />5 SEAT5. SPRING5 SEAT5. SEATR <br />6. MODULE6. OTHER6 MODULE6. MODULES <br />7. OTHER7. OTHER7. OTHER <br />0'□o CLOSED TIGHTCLOSED TIGHTFINAL <br />OPENED AT PSID PSIDOPENED AT PSID(RP) PSID(RP) PSIDTEST <br />0 OFAILEDPASSEDTHE ABOVE REPORT IS CERTIFIED TO BE TRUE <br />/(? ' S'? <br />ENDSTARTEND <br />f <br /><2: <br />DATEDATE <br />QUALITY SERVICE, IMC <br />BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />CHECK <br />VALVE #1 <br />o□ <br />o□o <br />0 <br />CHECK <br />VALVE #2 <br />o o o□ o <br />2. EXERCISED <br />REPLACED: <br />3. DISC (S) <br />4. SPRING <br />5. DIAPHRAGM (S) <br />6. SEAT <br />7. O-RINGS (S) <br />8. MODULE <br />9. OTHER <br />PRESSURE RELIEF <br />VALVE <br />PRESSURE TYPE <br />VACUUM BREAKERS <br />□ <br />O□ <br />O <br />REPLACED: <br />2. DISC <br />WATER CUSTOMER MAILING ADDRESS <br />\ U LtO te W)| EH ftVTHflV' <br />o □ o o <br />0 o □ <br />TIME OF FINAL TEST <br />CLOSED TIGHT <br />/ <br />SERIAL # <br />7^ / / <br />INITIAL TEST BY <br />SIZE <br />0 □ <br />0 <br />O <br />MFG isj. Ik <br />TIME OF INITIAL TEST <br />/O- 50 <br />START <br />DOUBLE CHECK VALVES | <br />REDUCED PRESSURE ASSEMBLY <br />O <br />O <br />LEAKED <br />0 1. CLEANED <br />INSIDE BUILDING: <br />SERVICE ADDRESS: <br />CITY, STATE, ZIP: <br />CERTIFIED TESTER NUMBER <br />MU I <br />NUMBER <br />SYSTEM PRESSURE: <br />MODEL <br />_______-Z? <br />ASSEMBLY LOCATION: <br />WATER PURVAYOR: <br />TYPE PiB <br />FINAL TEST BY <br />CERTIFIED TESTER NUMBER <br />_ ___// ^0: 1____ <br />NUMBER