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�aa �ggs-r�� � C01�1'�1�IVF,D �..o.,;ax�z8 <br /> BACKFLOW PREVENTION �4SSEM�LY Fi�e g€O�C�f�l���05 Moun[Vernon,WA <br /> !k'1273 <br /> TEST REPO�T ��`���'��"�3 <br /> OPERATIONS & ; «�^�� �� <br /> ��—�_� �IJ�AR— C MAINTENANCE ��"_������"lo�z <br /> NAME:_ --- <br /> MAILING ADDRESS — <br /> F ��� �r p�{- <br /> SERVICEADDRESS:�I�O S���VF�T ��` �� �--y�'��'~�� r <br /> �ocnriou:�'a' ��'1e1 �. i n1 �T(7�LE Fa�� -rv Mc7P �llt���c — <br /> CROSS COP'uECTION CONTROL FOR: ��(����_�N A'""i"�a -�1���/— TYPE ASSEMBLY: �-V� <br /> MANUFACTURER:���T.4 MOCEL: dC��I MI � SIZE: � SERIALNO.: �y� � ZZ <br /> INITIAL TEST RESIILTS TEST AFTER REPAIR OR CLEANING <br /> No.1 Check: Closedtight................ �l psid No.1 Check: Closedtight................ ❑ psid <br /> RPBdLoaked.......................❑ leaked.......................❑ <br /> QR Rcliel Valve Openad.................................. psid Relief Valve Opened .................................. __psid <br /> RPDA No.2 Check: CloSed lighl................❑ No.2 Check: Closed lighl................❑ <br /> Leaked.......................❑ psid Leaked....................... ❑ psid <br /> Passed Tost: Ye:: No Passed Test: Yes No <br /> �lo. 1 Check: Ctosud tighL...............� �Psid No.1 Check: Closed tighL............... ❑ p�i� <br /> DCVA Leaked.......................0 Q Leaked.......................0 <br /> �R No.2 Check: Closed tight................� 1� v psid No.2 Check: Closed tight................ ❑ psid <br /> DCDA Losked..... . ❑ Loaked....................... ❑ <br /> .......No... <br /> Passed Test: Yes_� Passed Test: Yes No <br /> Air Inle�: Opened_ Dsid Air Inlet: Opened psid <br /> Failed to open.........................❑ Failed to open.........................❑ <br /> PVB Check Vatve: psid Check Valve:_ P5� <br /> Leaked....................................❑ Leaked....................................❑ <br /> Passod Test: Yos__ No P�ssed Test: Yes__ No <br /> o• . • • . ' <br /> AG MinimumSeparation: Yes_ No__ . • . • • <br /> ISTHISAPROPERINSTAILATION7 YES�_ NO CUSTOMERNOTIFIED YES � NO <br /> WATER FOUND: ON�SC OFF 0 WATER LEFT: ON� OFF ❑ LINE PRESSUi3E:�D <br /> 7est Equipment: Make�.Q=.�"��S'�Q�. Model f+�Q.�� Serial il y��— Accuracy Venfication Date��/� <br /> TEST MEfHOD w�- �� �� <br /> REMARKS: <br /> � � � f�4 1���� <br /> � �( � � y� �Q-� h 6 <br /> Ini6alTeslBy: � �1��'Yl.�� CoriNo.9�i�iz�_ Date . `� <br /> TryeO a PnMe7 Date . <br /> Repaired By: ---— <br /> RepairTest By: _ Cert No. Date <br /> TypeCaPnMotl � !7 --.... <br /> ICGPTIFYTHEABOVEREPORTTOBETkUE: Certified�l4 5�� <br /> WHITE COPY(WATER DIV) YELL W OPY(CUSTOMER) PINK COPY(TESTER) <br />