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.. . . _,osa�c.� .. . _ . <br />. � � ���H'���F�' L/�' - <br />l� <br />BACKFLOW PREVENTION ASSEMBL <br />TEST REPORT <br />RETURN NO LATER THAN <br />JAME 0� �REMISES f'RE� D�E� l:A S(� 0 —FnF No. <br />iERVICE ADDRESS � I O 3 ��` �-C-'7 (�'<'� � � 7 , __ ^„ _ <br />.00ATION OF ASSEMBLY � 1 15�T f C-L�J� Y ('�`�.rJ / N t; T / ti <br />SSEMBLY: w�T7 S �� r <br />MANUFACTUREH MODEI <br />NE PRESSURE AT TIME OF TEST �U LBS. TYPE OF ASSEMBLY <br />�v 9g�s'S' <br />SIZE SERUL NO. <br />� i i <br />e <br />Reduced Preuure Assembliec Preasum Vaeuum &aaker <br />Double Check Assemblies pelie� ��nlel Check Valve <br />1s1 Check 2nd Check Valve Opened al <br />_ _ psid psid <br />Inilial DC-closed �, �ht ........� Closed tight.......� Opened al Did not <br />Tesl RP-��psid Leaked ................ ❑_,ir_`L psid open............ � Leaked ............ ❑ <br />Leaked ........................ ❑ <br />Repairs <br />and <br />Malerials <br />Used <br />Test Afler DC-closed lighl ........ ❑ Closed tight........ � Opened at Opened al psid <br />Repair RP-_ psid psid psid <br />AIR GAP INSPECTION: Required minimum air gap separalion nrovided .... Yes ❑ IJo ❑ <br />AflKS: <br />ABOVE REPORT IS CERTIFIE/DJ TO BE TRU 'y G � /J �7 <br />aL TEST PERFORMED BY v " w� CERT. N0. � ZZZ� . DATE �/' I�I9 g'.. <br />. <br />.IRED BY _ DATE <br />. TEST PERFORMED BY CERT. N0. DATE <br />19 �OPY�IOjS��Lj'A <br />