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J’:;: <br />BACKFLOW PREVENTION DEVICE TEST REPORT <br />/ ■ ff,. <br />J- . • <br />METER NO. CITY SERVICE ADDRESS -■ <br />LOCATION OF DEVICE '.L ‘.>L M- <br />TYPE:SIZE MFR. <br />SERIAL NO, MODEL NO. DOUBLE CHECK <br /> REDUCED PRESSURE <br />PRES. VACUUM BREAKER Q <br />5? <br />REPORT OF TEST RESULTS <br />Reduced Pressure Principle Assembly <br />Double Check Valve Assembly <br />m »2 <br />J»SI .PSI <br />OPENED AT PSID1. CLOSED TIGHT <br />DID NOT OPEN2. LEAKED <br />CLEANED L> <br />o1 <br />j. <br />DIFF. PRESS. PSI..PSI□IFF. PRESS.. <br />PSIDAIR INLET OPENED AT PSIDPSIDRP <br />CHECK VALVE PSIDREDUCED PRESSURECLOSED TIGHTCLOSED TIGHT <br />INITIAL TEST BY 7 DATE.CERTIFIED TESTER NO,A <br /> DATE.CERTIFIED TESTER NO,FINAL TEST BY. <br />COMMENTS: <br />THE ABOVE REPORT <br />IS CERTIFIED TO BE TRUE <br />(jof/vnercial - <br />(209) 334-9693 DATE SIGNATURE. <br />I <br />Rick Wahl, Owner <br />License #632919 <br />3 CHECKVALVE <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 />DIFFERENTIAL <br />PRESSURE RELIEF <br />VALVE <br /> <br />O <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 />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 />PSID <br />CUSTOMER: <br />77 <br />PSID <br />a <br />w <br />i-.:. <br />7 <br />i7 <br />!? <br />o <br />PHONE NO. I.' / - '-y-- <br />. //,< 6th/- <br />' DEVICE INFORMATION <br />< % ■ MFR. .■ /. v/Z /<• S <br />AIR INLET t£:- <br />OPENED AT ■' <br />DID NOT OPEN <br />• Backflow Certification & Installation <br />• Sewer a Drain Replaced a Repaired <br />• Water Heaters • Bathtubs <br />• Toilet & Faucet Repair <br />• Disposal Installation a Repair <br />1. CLOSED TIGHT <br />RP PSID <br />2. LEAKED <br />z <br />' •, z;:«- x /')