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� _ �/ <br /> � ; IVED <br /> � American Society of Sanitar.y Engineg�r�n�2o�1 <br /> Pressure Vacuum Breaker Assembly (PVB) <br /> � ASSE Standard#1020_F.ie.id Test Report C�'�'y OF ORONO <br /> � ' ° awner of Property t Vp c'�'b,���S� ' <br /> � Address � V. ��� <br /> �' �ity��rJ� S'�ate_� Zip Code <br /> � '' �ccupant of Property(if different from owner) <br /> �: Cccupant Address <br /> � � City State Zip Code <br /> � - ! �;�anufacturer of Device: �nf <.����S - Modei#: � � - �' <br /> � - Size of Device:_l�' Serial#: C�Z�(aZ� `7� <br /> ; �ocation of Assembly and Equipment or System Application: S i t�� o � �v`�� <br /> �. c�`�ti �Qr-3 <br /> � x <br /> ; ; Test Equipment: 1 <br /> � � " P.lanufacturer: � ` Mode!#: ��- �cK��l 1�,� Serial#: ��C�O�Z I <br /> ; ; <br /> ; ` Calibration Date: ( 17 <br /> � ' '� Date test was performed: Time test was performed: 1��.� Static Line Pressure: <br /> ; <br /> � � ! � Air Inlet Valve Check Valve Shut Off#2 <br /> � <br /> � i <br /> � Leaking ( ) <br /> � , N Faited to Open Closed Tight O Leaking { ) <br /> ` Initial Test <br /> � ' r Opened at psid Pressure Drop Across Closed Tight O <br /> ' { Check Valve#1 psid <br /> � � } <br /> ; � Describe parts and <br /> � � + repairs when needed <br /> � � <br /> � � Leaking ( ) <br /> Opened at o�_�g psid Closed Tight (✓}� Leaking ( ) <br /> � Final Test Pressure Drop Across Closed Tight ( <br /> � Check Valve#1 r.5 psid <br /> � Certified Tester(print) CC.VY� 6 1�2 Assembly Final Test <br /> Address ��fo Ue, � Perfo ce <br /> � City n State Zip Pass <br /> Phone#: �S'Z-ZIZ,-�(,(p3 <br /> � License#: C. Certification# S�� �v�'L(� Fail � <br /> � Signature ' Date:��� <br /> ! Comments or Recommendations(continue to other siae,if needed): <br /> � �N��s C�sn , �..���.t_ L,.-,�f-c� <br /> , <br /> E <br /> � Cro.rr-Connectio�i Control ProfesrionalQ�ralificationr Standar�! 77 <br /> � ==�3.SSE Serie.r 5000-2009 <br />