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ASSE International <br /> Pressure Vacuum Breaker Assembiy (PVB) <br /> ASSE Standard #1020 Field Test Report <br /> Qwner o roperty % '' ' � <br /> Address -� � u <br /> City ��-� Zip Code �S 3 � <br /> Occupant o Praperty (if different from ownerj � Ce �"� <br /> Occupant Address <br /> C�ty State Zip Code <br /> Manufacturer of Assembly: �l � f���� � Model #: � Z- (� <br /> Size of Assembiy: � Serial#: �' <br /> Location of Assembly and Equipment or System lication: ; G �'`-� <br /> �,.� ;,^ - ' ,� <br /> Test Equipment: , �,,- -.. � �� <br /> Manufacturer: +'��. :� --- � �� Model #: �� � - � Seriai #. � � f '�� �"'; ! <br /> Calibration Date: � -- M^�-' � - <br /> Date test was performed:�,�me test was performed:�(, ���Static Line Pressure: � '��� <br /> ; Air inlet Valve Check Valve Shut Off#2 ; <br /> ; <br /> j j ' Leaking ( ) ; <br /> ; ! Faited to Open ; Ciosed Tight { �/� � Leaking ( } � <br /> ' lnitiai TesE � ' ' <br /> i � Opened at�psid ; Pressure Drop Across � Closed Tight (� <br /> � Check Valve#1`� ?.� psid <br /> � i <br /> � Describe parts and � � � <br /> � repairs when needed � j � <br /> i , I <br /> 1 <br /> ; � Leaking ( ) ; <br /> ! � Opened at�7'�psid Closed Tight (� � Leaking ( } ! <br /> ! Finaf Test Pressure Drop Across ' Ciosed Tight ( � <br /> i Check Vatve#1 �_�--psid i <br /> Certified Tester (print) <br /> ,�_� + `, , 1-�.�, ,,1� -�_ Assembly Final Test <br /> Address ^--�_`� - -�. �t ! � Performance <br /> �- . i._ ..,-1� _ 1 - <br /> City _ `� State `�1 Zip -- '> Pass <br /> �. <br /> , _; _ -. -, . . <br /> Phone :: -- � ,�I ; - �# <br /> License�- �'- �'� �'� C rtifi ion# - -' �' ; ;-,. � Fail � <br /> � ` Date: �O� � � � <br /> Signature �.--� <br /> Comments or Recommenda#ions (cont;nue to otner siae,if neededj: <br /> � <br /> i <br /> i <br />