Report 4A.
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883842
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' P NWS -AWWA BACKF T LOWASSEMBLYTl -�
S REPORT ❑ REMOVED'
PROPERTY P � O l 0 REPLACEMENT
OWNER: r c ` V (fi
.�ftP- y�-tst f J-
�p S CflYUji4F.4 PHONE•
I II s: . .iB ui - d 03 ..l) STATE 0/1- ZIP 3Z224
ASSEMBLY
ADDRESS:
STT"T
DR_P_A.A.A D.C.V.A- CI RP.D.A. [1D.C.D.A D.G.D.A. Lir.V.D.A. • 173.V.DJL. p &v_B aAIR GAY
SIZE: LI1j•p.$DI MAKE: � Q
WATER r C'9'D MODEL: g�
PURVEYOR: SERIAL
ASSEMBLY NUMBER: tICi l S'` �-?s
LOCATION: * j r -- )) fl Qi
•
REDUCED PRESSURE . ASSEMBLY P.V.B.A / S.V.B,A INITIAL TEST _ �
•t CI ICCK PileMealatin AIR CHECK PASSED /
PRESS DROP (A)1 aim( in ' INLET. FAILED ❑
INITIAL. RELIEF VALVE
TEST OPENED AT u�u KW (B)'TIOHT 2e O AT. map
OP DATE'
R
•
ESULTS BUFFER LLEAKLW /�']
A - B MIN PSI I CHECK PSfO PSID /I 1L
RELIEF VALVE 'TIGHT DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ 'LEAKED❑ 1S° OPEN ❑ ❑ PSI
• OOMMEpfl
REPA1Wt
• AND /OR
PAM
REDUCED PRESSURE ASSEMBLY
ni CUE= P.V.B AJS.V.BA AFTER REPAIRS
EST PRESS DROP (A) CHECK Ill DATE:
AFTER �� I OPENE AT- PRESS DROP
OPENED ON TIGHT ❑. PSID
REPAIRS our= - mama* '
A B - CHUCK W2
wr ■ry ITTGHT ❑ PSID pryp PsTD PASSED ❑
IN COMPLETING AND s1JBMfl fl)JG THIS TEST REPORT. THE TESTER CERTIPIEs THATTHE
ASSEMIB.Y HAS BEEN . TESTED AND MAINTAINED IN ALY'nROANCE AVM ALL APPUCASLH
RULES AND REGULATIONS OP ATE WATER - sTSTEN, AND RATS REGULATIONS,
GAUGE CALIBRAT) r► ,L :P 0 1 DETECTOR METER' READING
TESTER SIGNATURE f /ar
TESTERS NAME PRINTED . earr
TESIEADDRESS J ��
RS
_ r. .4 j PHONE
COMPAN NAME - - .,
REPORT RECEIVED BY. OREPR�AnVE OP OWNER) "ERVICE RESTORED
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