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FROM : E. W.DAY PLBG & HTG PHONE NO. : 473 8403 Mar. 13 2006 10:40AM P2 <br /> 4715.2260 <br /> Annua) Testing <br /> of R.P.Z. Valves <br /> BACKFLOW PREVENTER TEST REPORT <br /> 1 ADDRESS a DD ec/�©.O fj, ®CITY 0� ? <br /> ZIP .5��pe, <br /> OWNER� ,e,e,"G <br /> c® �cc�u�j TELEPHONE NO. DATE:J J`j i <br /> MAKE AND MODEL OF DEVICE 1,"d'` '4i�f SIZE / it 1 ` <br /> 2x4,4, 9 z.�-X4- SERIAL NO./ 9 1? <br /> LOCATION OF DEVICE: - <br /> CHECK VALVE #1 fCHECK VALVE #2 PRES. DIF, PRES. OIF. STRAINER <br /> ACROSS #1 WHEN RELIEF <br /> IBT LEAKEif LEAKED ) CHECK OPENS <br /> BEFORE CLOSEDCLOSED .) �si v •9Psi CNLND (NE ) <br /> REPAIR <br /> DESCRIIE <br /> REPAIR <br /> FINAL LEAKED ( ) `LEAKED ( ) psi - psi <br /> TEST CLOSED ( ) <br /> MkTERIALS <br /> USED <br /> . <br /> CERTIFICATION: <br /> I hereby certify the foregoing data to be correct and that the tested device is <br /> functioning within the limits of the standards. <br /> FIRM NAME i. •w Ar/ - ADDRESS ,(J%4 z---- , -a-e--- <br /> B . 29,6,1g_ TESTER'S CERTIFICATION NO154-0,0,Y7 TEL. NO.457 YZ?'S''o3 <br /> DATE 1 REMARKS <br /> 6',4/b7-e),4-/=- "2-74,,i,- <br /> . <br /> 5 , <br /> E <br /> c <br /> i <br /> • <br /> , <br /> C <br />