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Arno 41-so-200- LIWIO <br /> BACKFLOW'DEVICE TEST REPORT <br /> Service Address 450 C7 VJi f ov4 l r^ 0-rV12(2 <br /> Name of Premises._ I'I } ua �a r) Location of device~ s <br /> Device 1�d bei/2? 3 a'-I—a 11� <br /> MQ" SMai Number <br /> Test Kit <br /> MamFacarer SSW unbar : Date OWMW <br /> RP ❑ <br /> DC ❑ <br /> DCDA ❑ <br /> RPDA ❑ <br /> Reduced Pressure Principle Assernbl - ;,.. <br /> Relief Valve Check Valve#2 Check Va;e-#1 No.2 Shifioff Check Valve#2 <br /> Opening Point Backpressure Test Valve <br /> Opened at psid Closed Tight ❑ Heid at _,Vsid `Closed'fight ❑ Held at psid <br /> Leaked 11Leaked ❑ Leaked ❑ <br /> Did not open ElLeaked.� ❑ <br /> Double Check Valve Aaserly Backflow <br /> Assembix status <br /> Check Valve#2 Check Valve 91 140.2'sfiutoff Check Valve ilk <br /> Backpressure Test VON* Passed R <br /> Closed Tight © Held at psid ' Closed Tight ❑ Held at psid Failed 0 <br /> Leaked ❑ Leaked i Leaked © Leaked ❑ <br /> Time �- 2(a Certified Tester# A -15 - <br /> Test by(Signature) print Name of <br /> Your signature certifies that all info anon provided on this section is correct. <br /> Comments: <br />