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New L7 <br />Existing ❑ <br />Replacement ❑ <br />NAME/COMPANY: kV� Lle.wevfoo.ry Contact Person SFeje Kr4l—$L <br />SERVICEADDRESS: Qof-{,. Et/t✓ f{ Phone Number HZS- 3?X -q/9& <br />LOCATION OF ASSEMBLY: �_3a:�d-!'IS <br />CROSS CONNECTION FOR: igrr /1 <br />ASSEMBLY INFORMATION: r O [�FC7479M3CZ- 3/y f-'.P yzz S <br />MAKE MODEL SIZE TYPE SERIAL NUMBER <br />INITIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING <br />Line Pressure pis psi <br />Pressure Drop Across Pressure Drop Across <br />No. 1 Check Valve (A) �. uSid No. 1 Check Valve (A) psid <br />Relief Valve Opened (B) 3. Z psid Relief Valve Opened (B) psid <br />RPBA <br />No, 1 Check: Closed tight ... []� No. 1 Check: Closed tight loll ❑ <br />Leaked ........ Moo <br />❑./ Leaked ..........❑ <br />No. 2 Check: Closed tight ... L d No. 2 Check: Closed tight -----❑ <br />Leaked .........❑ Leaked / ........._❑ <br />Minimum AG Separation Yes ✓ No _ Minimum AG Separation Yes _ No _ <br />Passed Test Yes No Pass Test Yes No <br />Line Pressure psi <br />No. 1 Check: Closed tight -❑ pSid No.1 Check: Closed tight ..0. pSid <br />DCVA Leaked .....loll 0 , psid Leaked .loll....❑ pSid <br />No. 2 Check: Closed tight .. P _pSid No. 2 Check: Closed tight 0.11 pSid <br />Leaked.........0 _pSid Leaked .....__..�. pSid <br />Passed Test Yes No Passed Test Yes No <br />Line Pressure psi <br />Air Inlet: Opened psid Air Inlet:Opened psid <br />PVB Failed to open Failed to open... <br />Check Valve: sid Check Valve: pSid <br />Leaked..._....... Leaked _._......Q <br />Passed Test Yes _ No _ Passed Test Yes _ No <br />AG Minimum Separation Yes _ No _ PLEASE RECORD REPAIR OR CLEANING <br />Diameter INFORMATION IN "REMARKS" SECTION BELOW <br />Assembly Tested: Satisfactorily Failed _ Water Service found: On <br />IS THIS A PROPER INSTALLATION? Yes No _ Water Service Left: On off. <br />REMARKS: <br />Test Equipment: MakeYt(:cti'JrSl Model k`/S-S Serialt7 032`?(2RL Accuracy Verification Date K' 22-23 <br />I CERTIFY THE ABOVE REPORTTO BE TRUE: <br />v ry (()¢'.(�., Test Procedure Used ?510 <br />Certified Testers yped or Pr tede t3 �� 4 g <br />initial Test By: �'-� Cert No. <br />Signature <br />Repaired By: <br />Repair Test By: <br />Signature <br />Cert No <br />Cert No <br />3bo <br />Phone No <br />Date I C7-! 3- 23 <br />Daie <br />Date <br />Signature <br />