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� ��� �� <br /> � REDUCED PRESSURE BACKFL01J�1{, PREVENTER TEST REPOR� • <br /> SERVICE NAME G��'J 5 Z�. COt�fTACT PERSON ���`fs <br /> ADDRESS ���-� G R e� T�s�,S 2��J� pHONE NO (�� 5 � S' - 1!'��' _ <br /> C�TY O �� N � ZIP ��3� � <br /> . �1 <br /> GEVICE LOCATI4N �L'� ��- S� , t o �� ���=�c. _SERIAL NO. I Q 1� � � SIZE j ' .. <br /> TYPE & MODEL (nJ�-f-� 5 � � �� SERYES W HAT SYSTEM � ��'.� 4 �t�+ a lJ _ <br /> INSTALL DATE '�- �� � �'� OV'ERHAUL DATE ' TEST DATE ��'��� "�Z—_ <br /> �{'�`�; ' ' <br /> r���u, � CHECK VALVE WO. 1 , CHECK VALVE NO.2 . DIFFEREhITIAL PRESSURE <br /> REUEF VALVE <br /> � ' , Opefled 8t :�, 1-5 � GSid <br /> ANNUAL 1. LEAKED 1. LEAKED ' reduced pressure, <br /> TEST 2. CLOSED� 2. CLOSED� Did not open � • <br /> Cleaned Cleaned Cleaned � ' <br /> Replaced . ' Replaced ' Repiaced � • <br /> pi� � . p�� Disc, upper ' <br /> Spring • Spring . Dlsc. fower <br /> Guide Guide ' � Spting . <br /> � Pin retainer � Pin retainer Diaphragm� l.arge <br /> Hinge pin � Hinge pin. �� _r upper <br /> Seat • � ' Seat lower <br /> REPAIRS Diaphragm �Diaphragrn _ Diaphragm;Srnali <br /> Other, describe below: • ' Other, describe be{ow: upper � ,� <br /> � � lower . - <br /> . SEAT: <br /> � �PPef . . <br /> � lower <br /> ' - ' � Spaoer, Iowe� � <br /> • ' Other, describe beiow: <br /> =iNAL CLOSED CLOSED Open at psid <br /> rEST . reduced ssure. <br /> fested by (PRINT NAME) �� ' t�� I�C,�t K q i. l-� � Certififica�ion No. � � <br /> fester Phorie Na. � I . - 2Z ( - y " • . <br /> �HE ABOVE IS CERTIFIED CORREC7: Signed � Date " � ��' � <br /> 'Iumbing Company Name �`'� � u^�►���� License No. 3��� , <br /> ;omparry Address ��� / 7�' �v�e r•r�t �L� Ciiy��10���� C _ <br /> ,. <br /> 3fate � � Zlp �S 3 Y.� Phone No. ti(_S"L ) �3 3 - ,��3 6 <br /> i 'd Xd� 13C2i3Sd1 dH WdB� =L LOOZ Li �eW <br />