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� <br /> � <br /> � <br /> : <br /> � American Society of Sanitary Engineerin <br /> � <br /> Reduced Pressure Principle Backflow Preventer (RP) Fc <br /> � ASSE Standard#1013 Field Test Report F/�j <br /> . <br /> � e�ti� 7 F <br /> � ��.:���er of Property C ' ���;- <br /> ,� ,=.�dress Z. Lc� c�c i,,� O <br /> � ```� a��� State Zip Code � <br /> � �ccupant of Property (if different from owner) <br /> . <br /> �c�upant Address <br /> • ^�� , <br /> � "�� State Zip Code <br /> : ',��nufacturer of Device: (� �` ^�, S M4d�el#: /7� k� <br /> � S;ze of Device: C�' Serial#: `i ZS Z��V <br /> '� _oca"tion of AsCT�embly and Equipmp'(nt or System Application: Si D�' � �v�� � <br /> � �� �Vl 1 •ii(�� � 1 � ��Yl L���_CL��f a[\ <br /> i <br /> � �\ <br /> V <br /> � <br /> ■ <br /> -es� Equipment: <br /> ; t�;lanufacturer. Model#: �O-Z.Q(,Z-- ��,U Seria�#: Q�-IIG"��72.+ <br /> s <br /> C�libration Date: U ' <br /> . W�11 p�� <br /> ' Date test was performed: �z 1 Time test was erFormed: "'���11�h� � <br /> E P '� Static Line Pressure: <br /> r <br /> � <br /> ' ; Check Valve#2 Shutoff valve#2 Check Valve#1 Pressure Differential <br /> � Relief Valve <br /> ; ' � Leaking ( ) Z-7 <br /> ' i lnitial Test Leaking ( } Leaking O Closed Tight � <br /> s ; I Closed Tight,� Closed Tight J�j Pressure Drop Across Opened at_psid <br /> � � t � Check Valve#1 sid <br /> � ' <br /> � ; � � Describe parts 1�7,�Z <br /> i � and repairs <br /> i � ' ! when needed <br /> � Leaking ( ) <br /> � ' '' Finat Test Leaking ( ) Leaking � � Ciosed Tight ( } <br /> � � Closed Ti ht Pressure Drop Across Opened at_psid <br /> M . { � g O Closed Tight O Check Valve#1 <br /> psid <br /> , ; <br /> F i Certified Tester(print) J�ttrn7 w �l�Z Assembly Finaf Test <br /> ; Address ��\Ly �.�`��� Performance <br /> � � <br /> � City_ �.�' �%+�_ Stat 11/� Zip S�S�� <br /> � Phone#: ��2-Z�Z L.� ����_ Pass <br /> ' � License#: ln � Certification# Z8�`16 � <br /> � i Fail ❑ <br /> � Signature ` Date: �'! �2 <br /> : <br /> i <br /> Comments or Recommendations (continue to other side,if needed): <br /> � <br /> � <br /> � <br /> � <br /> � <br /> � <br /> � Go.u-Co�rnection Cartrol Profe.rrional Orra/ificatia�t Stanrlard �� <br /> _-�SSE Series 5000-2009 <br /> i <br />