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Report 4� f G. ';� _ ✓J {✓, s f�q �t '° � 6 M1 �° 4 A �" - R.�'*S '1.W 1'�7�F� f b Y A -•t �` }� - Asn•. 7F q, : _S. �t�r ..,: s �" �� NE-W •:}. . r, ® 7CISTING ® k a f, x r� PNrWS AWWA AC, ,❑REMOVED P.N;WS AWtW?. d ' E}CI$TING A Er ACKFLOWASSE`MBLY<TEST�REPOR�� OEREMovEDW r B ❑REPL CEM ❑REPLACEMENT; PROPERTY i Y r OWNER "C 't 7d" l 1� Il $Z ALl .jl .:. .PHONE: PROPERTY MAILING OWNER �1 G.tr f7c$'YLtC.- £ N1 "Q PHONE rt / r d 1 t i- / !- I ! �' MAILING 'k t2 ✓ bh ADDRESS: ? 4�l� i ) C._s, '� ` .£ a� .:' Lei r``�: +~_l�__i',. ! ADDRESS. . r 4' CITY STATE' L ZIP ,,I X53; 21 n CITY STATE ZIP ASSEMBLY._ t�, i ! MBLe ADDRESS �� C� Y`'� C1I. :t�_g 1�,-01 . i ASS:' Y � �_` STREET ESS ' li I ) ADDR n STREET r ❑R P B A D C UiA ❑ KP D i1,'.: D:C:D A.- ❑P.V.B.A: ❑&V.B.A. ❑A.V.B. ❑AIR GAP a } w Y ❑RPBA* DCU�A;r❑ RPDA$r❑?DC'DA '°❑PUBA�t(]SVB�E1{ AVB ❑_AIR SIZE U � ' MAKE: t Sri t MODEL:: `` i �`� `" xMAKE G WATER r SERIAL SIZE n WATER SER, PL)RVEYOR' TC«� tf #n NU BER; A2,0 PURUEI'OR R:., �• ASSEMBLY _ rLO.. T ` . :� ` ASSEMBLY f! s x a CA ION •y�...p�"" ��j'l -. `. • • . 'ASSE.MP.V.B. SV.B.A ' ,T-ESTREDUCED'PRESSUREITIAL - REDUCED S u z _ INITIAL-TEST A.OU$ E. HECI .. PASSED,_:- RES :> al:�cHECK CHECK:, Pad x ;< `r' ,y AC} t3LEIiECK -AIR CK PASSED z PRESSDROPr'r.r. ...:.INLET FAILED. ❑ gICHECx ss ra✓.r 5:> r. CHECK'#1'.. , . . , . ., e..r• PRess uROP (- ) x�, LNLETI y FAILED �. - £ 2,'a,::GHEGK.#I N < .,r',t s_ _ `❑t. r.• RELIEF VALVE 3. " 1iy v'a 1 INITIAL_ - y, 'G a., OPENED AT:=PRESS. R P ?x.^ `Y" - n ".,>"' t TIGHT, �" �b.o =� .p::_...�,, OPENED AT' ,,,.✓ :..- -)- a :. ,, • +::. ._ .,, x _. ., INITIAL RELIEF�VALVE ro ,a r r;� d +t P - ...TEST '* <. �, .-„.;�,o. .. ✓ ,. fi .: t8 TIGHT OPENED ATa. PRESS DROPS S r' .. r.-:':iMIN.2`P;SID ';1 :. ",` .,P DATE: OPENED AT. r <#,�:-.�.. ) ^ - ' LEAKED❑ : TESt y k , r , sDATEr ,=':t + RESULTS BUFFER 'ar [Dx4 � FAKED(] ` .y+ <�• MIN 2 PS ID tr c, B CHECK#2 P S BUFFERtti? L PSID PSID s a Pslo RESULT ��. ,. LIIN3PS[: Zi DIDi:NOT -FAILED ?.',.SYSTEM „� 1ttN3Psf' �I * .;J n, �, ,. : ,;, _ F e* r I•rEDr a . �. RELIEF f '-, a� T-IGHT: 's / DID NOT FAL SYSTEM . ." 0FEM❑�� ,PSI V y.. ., «, ❑ RELIEF AL. t_. e.r f e.,.. ❑. y u k. 7 re tOYEN.mt zywa 7 :� xa ..PASS ',; ,: FAIL,,;, r ,_. LEAKED;- -. .. >,:.•; . a, vI PSD P ASS ,j SL'❑ Y y +R,t} fiTS. Ary;.,1 4 F t y„v ! -t<IL ra`❑ k fi- w..� '� : x x �.1. E 7• 3.�' :. y �r { ,r.} q ) tCOMMENTS ..W. 2 REPNRSi r.4 '} �* - •. .COMMENTS �t).AND/OR y,::_-: ,, o..; :; •.:,... REPAIRS . N. i r'`.✓ �`'✓ y;t'�i, ;x t �u--5 -''a• x k r s s ANDI.OR s.x k yq.,"iv. �r {t ,.vrtN s. ✓ ..,H., rcr•,=,.''i+sw� 'a. 'a'tt a'tx' y t, `' :,; e ''dt, 1,5t1�'W '] a r _.K} 5 rT 7' `cs : PARTS`' -a.'v."f' tot kt •t' :ti �i``'.^!~a. ,t 6+r7'x J, :,�.'�-at y 4 :i iMn Sell" L,'+ _ .:✓�:-. �° � ( :—f ➢ fi. 4 t�tL.JG�E� ..�.Y '� ,.:.r, t} k. . /s k 4Y k,4',L L�.7F -r�..A{�f;4)., F (..' t,r,. $ } : _ ,r3. } 3'' ( Yrrx 3.€., "KtF3'k ta"p;_.•4»,. 'rk.-fib`r-.. t!: REDUCED PRESSURE ASSEMBLY _'- -.YV'.B:A:&V.B-A: AFTER''REPAIRS . . .� E .. ... �.a..,<'�., - ,ZI:`ekEDUCED;P.,RESSi)RE ASSEMBLY • P V B.A/S V B:A .,."� :AFTER REPAIRS'`' . �'•'� C..V .. DATE: E AT a ttz :.N !.r'.; -.+�. ;RE(;IEP 'e., P 7` ,3' .td.=,*JS.•,�'.o- -OPEND,: PRESS,. P, .: ., ,:}� ..,'.:.•,... ..... t.:, iE" IA s:t. r�,a.r7. �-�'.t s's,tib..,".°, r , t•,,,;:Y.. t k� ( ;.c�'�,x AFTER -'` B ,I TEST F,4"!,11, fi h C CK # w ....::.. OPENED r `'• s<-- •':I-). T GHT.,❑�-. PSID.. - - .. DRO ^"-:_ ,:fir�:?�,Aa•?�' ,...+Y,.r. , e!�, s.,� `OPENED`liAT j PRESS DROPS -'� «?t�� a �, AFTER. � ��� ;e� TIGHT ❑ iF �, �r � H 1. •>i �" , `: REPAIRS ,BUFFER �• .CHECK. A B ".. _ #2', REPAIRSn� sr ;. ,,@,,�• LLT-IGHT ❑' :rslD PSID', PSID A BRtCH CK #2k PASSED PASSED ❑ E ... .. � :i:s. .- £- ..; xv. .K�+S zy,TIGHTIr❑M,�rPSID & . }'IN COFIPLETiNG.AND SU ,M!MT g'THIS.,TEST REPORT THE' 'PE¢TER CERT_IEIES.THA"C THE . . - _ `IN:COMPLETMG AND SUBM1ITfNGSTHI$.TEST REPORT THE TESTER°CERTtEIES THAT'THE ❑ ASSEMBLY HAS,BEEN TESTED�AND;MAINTAINED^IN-ACCORDANCE'Wf -'ALL H. a:., ASSEMBLY}IAS BEEN TESTEDAND MAINCAINED.IN ACCORDANCEtW17Hd?AI LAPPLICABLE a Y... s-.' .:...ftRIJLES�.:ANDRE.'ULATIONS .,OFA' E,r•;WATER AN UL .- r +I ,,.-„�a„ a.,,.,�;. ,..W_. f.,,.. -,.,. ;�, ~; tG <.f '.:. S• ."` RULES-:;AND REG' ATIONSr.OFA WATER SYSf EM t�AND�:';SFATEREGULATIONS 1. 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"' ,:: "a+'�yy "4"._ mtira�C �Conne on 03)235-614 �„� �'r .,.G+ -,t :. .. .: F: 'mac F4 r t :J,�,>.,:, flu COMPANY NAME z ' u. LSERVICE RESTORED r s: �• :.+,ac' i � �� REPORT`RECEIVED BY \ '-^>r ..r. -} x _ , ':.cICE,RESTORED -r, 't (REPRESENTATIVE OF`OWNER):t' ' _ r �. -•F RT,tRE �(REPRESENT$TIVE OFOWNER) a` STM . r s4 "c s Y` _y r _ REPO CEIVEDtBY