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. � UScv � oo� <br /> (�,�� � g g 5`ra_]�/ R E C E I V E C OlilI1lEPCl3� r.o.Qox�za <br /> BACKFLOW PREVENTION ASSEM9L�(�� Z � Fi�e Protection MountVerno��W3 <br /> TEST REPORT 2005 csco�snaso�,s <br /> �^� �OP�E�R.�yA-TIONS & r•a�c:(3f�0)&tE-lo <br /> NAME: �YLIIS^"'S ��DG�.2 S'�:i2'LS.�AN('F <br /> MAILINGADDRESS: _ <br /> SERVICEADDRESS:���� �VE(LFT (`nAl=Lz�NA� ����I� ��I�-S�I=-.7T��/_A- <br /> LOCATION: ��o `.l D� ���1�1i1 �v��-V� ��^ <br /> CROSS CONNECTION CONTROL FOR: �-C��L �C� �r�� ` TYPE ASSEMBLY: ���� <br /> MANUFACTURER:.�ti�L�1�.— MODEL: L�rI M�GZ\ SIZE:_L/Z SERIAL NO.: t s ���`� <br /> INITIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING <br /> No.1 Check: Closed tight................❑ psid No.7 Check: Closed tight................� psid <br /> HPBA Leaked....................... 0 Leaked....................... ❑ <br /> OR �eliof Valvo Opened.................................. _ psid Relief Valve Opened .................................. Psid <br /> RPDA No.2 Check: Closed tiqht................❑ No.2 Check: Closed light................❑ <br /> Leaked....................... ❑ psid Leaked.......................❑ psid <br /> Passod Test: Yes No PasseC Tesl: Yes No <br /> No.1 Check: Closed tight................� �^J psid No.7 Check: Closed tiqht................❑ psid <br /> DCVA Leaked.......................0 Leaked.......................❑ <br /> �R No.2 Check: Closed tight................� ' ° � psid No.2 Check: Closed tight................ ❑ P�d <br /> DCDA Leaked....................... ❑ Leaked....................... ❑ <br /> PassedTost: Yes� No PassedTest: Yes N� <br /> Airinlel: Opened psid Airinlel: Opened psid <br /> Failed to open.........................0 Failed to open.........................❑ <br /> PVB Check Valve:_ psid Check Vaive: _ P5� <br /> .. . . Leaked....................................❑ Leaked....................................❑ <br /> Passod Test: Yes No__ Passed Test: Yes.__- No_.____ <br /> • • . - • • • <br /> AG Minimum Separatlon: Yes No _ . - . • • <br /> ISTHISAPROPERINSTALLATIONI YES�_ NO CUSTOMERNOTIFIED YES_x'/_ NO <br /> WATEFi FOUND: ON� OFP ❑ WATER LEFT: ON� OFF ❑ LINE PRESSURE: 7O <br /> Test Equipmenl: Make t��'M�S"1�� Modol S2P'� Serial p ��� Accuracy VerificaGon Date �� Z U _ <br /> TESTMETHOD V��A _�'>� �'Z — <br /> REMARKS: <br /> �1,�, (S /� AJ�Se�_(� }S t.4[,A- <br /> IqVy1 r%I'\ cenNo. oa�o � 7—� <br /> Initlal Tesl By: _��� <br /> Repaired By:_ /� <br /> Date <br /> RepairTestBy: � GkHNo. Data <br /> TypoCorPnMoO ' / / --- <br /> ICERTIFYTHEABOVEREPORTTOBETRUE: Certified ��s.i� <br /> sqnaiwa <br /> WHIT[COPY(WATER DI� YELLO COPY(CUSTOMER) PINK COPY(TESTER) <br />