Report ...
1 '. 7 p
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BACKFLOW :iotisTiNc —
RP.MOVED
P NWS-AVVVVA PREVENTER REPORT REPLACED
REPAIRED OLD SiN:
PROPERTY NAME -r r, r PRONE
CONTACT NAME PRONE
MAILING ADDRESS
CITY STATE
PREVENTER ADDRESS 1. 4i.,2_,.&rit 1/401'
WATER surrunem SERIAL#
01.7.1
LOCATION -r _LI --c _
... „.„ .1-tripptt_ee als 4,4,... t-c.'S 5.'e,--1...i'e.r r'..-..,. ‘/-t. 1/0s4,41/-
MAKE 1.41.446144 MODEL SIZE Z ' _..,
,..........,
'TYPE [J EP 0 WPDA Ej RPDA-II 12 DC [.1 DCDA D DCDA-II Ei PVH I I SVB D AVD 0 AG
HAZARD PROTECTED PREMISES ISOLATION n IRRIGATION 1.: FIRE SYSTEM n BOILER E]OTHER
APPROVED:.51 ASSEMBLY 0 INSTAL LATION 11 ORIENTATION 0 AIRGAP PIPE SIZE in :: in
REDUCED PRESSURE ASSEMBLY PVIIA/SVBA INITIAL TEST
DOUBLE CHECK AIR INLET CHECK VALVE PASSED ji7A)
CHECK II CHECK RI_TYPE 11 1--] oetvenAr. MUM MOP
PRESS TIGHT te4, FAILED [1
IN rum.. _ ..... .„.....___..
TEST RELIEF VALVE LEAKED 0 MIN 1 MID MIN I Mill MIN I MO DATE /5,X.115
RESULTS INNIKNI2 AI: OPENED _..d
hat+,nu, CHECK VI P Mt r H FAILED SYSTEM PSIMO
RFT/PP VALVE: TIGHT -.z. DID NOT 0 DETECTOR METER
tPASSES FAJUID 0 READING:
LEAKED 17 MN I me
----
REPAIRS
NOTES
V6.t,IVe ZR../AS 4" r-eilm-ekree/ Lc, e,
PARTS
I' :I./al ek(744* 'Leff' c
REDUCED PRESSURE ASSEMBLY TEST
CHECK#1 DOUBLE CH PVIIA/SVIIA ECK AFTER REPAIRS
PRI,12:
trace
CHECK RI TYPE 11. [1 AIR INLET CHECK VALVE
REPAIR NOW= riGin- El tvsmsnAr Maas DROE
RESULTS REUEF vAl.vic DATE
mean
AT CHECK an Mu,i MN MIS I PSU) MIN I MD
NISIAM VALVE MIN 2 MD
TIGHT n Oril,E1/
FliLLY n PASSED [-I
PANES 0 VAIIIID 0 MLN I ISM
GAUGE S/N 074,2)„.156) MAKE/MODEL A(ed7t44,%/' -04/V"--CALIBRATION DATE
. .
In completing and submitting this test report,the taster certifies that the assembly was tested and maintained in accordance with all applicable
rules,law!,cotk and ,ulations of the state and water a Mon usin, u Roved leatin• at talent and approved teatingpmeedures.
INITIAL TEST TEST AFTER REPAIRS
: ,..
' .R ATURE 1 TESTER SIGNATURE TESTER irilif-4
i ,a' •-a,- ... 111111
i TESTER NAME(1 24117) .-ft76'.
(4.-ePie I TESTER NAME(PRINTED/ PHONE#
TESTER ADI)R L.S1 S ITS It'll ADDRESS EM A IL
COMPANY NAME COMPANY NAME WA rER RESTOR kW
0
REPORT RECEIVED BY(REPRINENI A ORE OF(IWNER) REPORT Rrcovi-D MV 021,,PNVNI-INTA row,o#owNER)
9 4( 26-Z-=-7-/9/(26- #Q 0
Pit/ri /of -, 61; 5-8"--