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BACKFLOW PREVENTION ASSEMBLY TEST REPORT <br />NAME OF PREMISE: <br />,9AMA <br />`F rDO-r <br />C 60i C, 0- <br />EUECt'.1t Commercial X <br />Residential ❑ <br />SER VICE ADDRESS. <br />3131 <br />1JQ55011.i <br />St. <br />CITr: xyerel1 <br />ZIP: 93,A0( <br />CONTACT PERSON: <br />PHONE: ( ) F.d.V.- ( <br />LOCATIONOFASSEMBLI'. Ajectk Fred " fir �8,AM;nn in Mock n cat oOm <br />DOWNSTREAM PROCESS.- iu Ic�intl /VItS1p—L_lumb;nq_DCVA: ❑ RPBA: S PITA: ❑ OTHER: <br />NEWIN:STALL: CK EXISTING: ❑ REPLACEMENT.• ❑ 9LDSER. # PROPER INSTILL.4T10N? )ESS NO ❑ <br />MAKE OFASSEMBLY.- WAILS MODEL: 009M a QT SERIAL NO.: _,57 % % 0 S17.E: Q " <br />D(71,A / RPBA <br />DCIA / RPRA <br />RPR.-I <br />PI'Bq / NI"R•1 <br />INITIAL <br />CHECK IAL1'ENO. I <br />CHECK IALI'ENO. 2 <br />AIRINLETt'ALI'E <br />TEST <br />OPENED . f T PSID <br />CLOSED TIGHT X <br />CLOSED TIGHT <br />OPENED AT PSID <br />LEAKED ❑ <br />LEAKED ❑ <br />#I CHECK _�, b PSID <br />PASSED X <br />AIR GAP OK?, <br />DID NOT OPEN <br />FAILED ❑ <br />ge S PSID <br />PSID <br />t _ <br />c'ECAX REPt_+CE PART <br />Crr4N RMACE PIR7 <br />cEE.+% REPIAcr P+RT <br />CHECK 1 ALI'E <br />NEW <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />NF.LDA7'__PSID <br />PARTS <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />LEAKED <br />AND <br />❑ ❑ <br />❑ ❑ <br />El ❑ <br />REPAIRS <br />CLEANED ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />REPAIRED ❑ <br />TEST AFTER <br />REPAIRS <br />LEAKED ❑ <br />LEAKED ❑ <br />OPENED AT_PSID <br />AIR INLET PSID <br />PASSED ❑ <br />PSID <br />PSID <br />#1 CHECK PSID <br />CHK TALI E PSID <br />FAILED ❑ <br />AIR GAP INSPECTION: Required minimum air gap separation prooded? Yes: ❑ No: ❑ Detector Meter Reading: <br />REMARKS. <br />LINE PRESSURE: 65—PSI <br />,'Lote.CIzd Ron FS ee Z Q CONFINED SPACE? CIO <br />TESTERS SIGNA TURE. �y,_,�. `t,.l, .-. CERT. NO.: B 5c3 DATE: /a'I b — 05 <br />TESTERS NAME PRINTED: BrentW.CroN TESTERS PHON'E.(.'_z)S^t1-1138 TESTERSEMAIL: ix itrc�' rtt,r.con: <br />REPAIRED BY: <br />FINAL TEST <br />TE: <br />CERT. NO.: DATE: <br />CALIBRATIONDATE:09/27/05 GAUGE. Mid West Instruments ,YODEL: S30 SERI WE RESTORED? 1'ES. X .VO: _ <br />eerdJ that this report is accurate, and I have used II A C?J6-:90-J90 approsrd test merha ds anrd int equipment 13 <br />Baclrit ow Prevention Assentblr Test Report must be filed with local !Pater District br Owner a remise <br />