Report o(L • A341511
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STIN
BACKFLOW Lit TES . PORT 0 REsovED:
4. 0 REPLACE NT
PROPERTY Ulf t' .
OWNER: Ol'P r1 PHONE:
NAMING .
ADDRESS:
CITY STATE, • ZIP
ASSEM*LY 13 S ERE T t S %(.4) I 94
ADDRESS:
Sf
OR.P.B.A 1 D.C.V.A O R.P.D.A. OD.C.D.A. DftV.B.A OS.v.aA 0A.V.B. OAIR GAP
SIZE: LJJ J•I DIO_I MAKP E: 'qv( 1�[ODEt '`:a O 4`
WATER SERIAL . f] a
PURVEYOR: NUMBER; �T`'1 r
ASSEMBLY
LOCATIO _______ _______
N: .. A. L
________ ,__________
REDUCED.PRESSURE AS .Y P.V AA / S.V.B.A INITIAL T ST
CHECI( AIR CHECK r PASSED
IAI1 CHECK ie INLET PALED [[[„j]]
INITIAL RELIEF VALVE B TICIHT OPENED wr. PRESS- DROP
TES MELD AT MAIN D l )� D D TE.
RESULTS - LEAKED❑ /i b
BUFFER
A•B MIN 3 PSI I CHECK #2
TIGHT t. RID NOT FAILED SYSTEM
REU EF-VALVE rap OPEN 0 0 PSI
PASS 0. FAIL C). 'LEAKED L7
comm ENii 4- ) s cv
REPARIS
AND/OR
PARTS
REDUIT4I'k1RE MBLY P.V.B.A/S.V.B.A AFTER REPAIRS
EItSIB(nu - ? -• ' DATE:
TEST
1wr.11011 w 01toP (� CHECK.Fl D AT PRESS DROP
AFTER OPENED (B) TIGHT 0PS10 t
REPAIRS "' ' CHECK NE '
surpER
A"B= ��riF`—'I`LIGHT 0 PSio PASSED 13 .
IN COMPLETING AND SUBMMI17NG THIS .THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED *• •ANCE WTIH ALL AFPUCA*E
RULES AND REGULATIONS OF THE WATER SYSIl, AND STATE REGULATION&.
GAUGE CALIBRATION DATE la/ 4<"-DETECTOR METER READING
Ir
TESTER WHAM/RE (Instil
> c, • p t, A : +,r a
f It
-t
7ESIERS NAME PRINTED lc 3)(45 _ } 1 �V(, s l
TESTERS ADDRESS ( /,? ` / PHONE N
ODMPANY NAME ` ...r?' :--,
=-r, I ,SERVICE RESTORED
REPORT RECEIVED BY: (RRPWINTATIVE OP
WHIiT-Waist Epilogs Copp PINK•ceiworO y Y •TWIT CAW . _::. _