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YUSMSSADURM: T59 I Cov4y Q IQ q o f -- 19 '7
NAME OF TESTER (PRL%7[ ; ;�ti SFGNAT M; 7A J
TESTER'S STATE OF M CERTIFICATE NIMBER: CR84.
CERTIFICAT1CN-. I menti 19+ean6 n*Frve xtic^ P^^id°° 6- Tco, Lo 1kr:Jl yea OL din -JF 1-m:i dev.oe •s "mLUmi*1n IFr IimIF ,F =�.idlydl
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OF ASSER 13LY_
MA"IrL:-FAi7.5, bU-R 1 ]F• A.5N FM UL V!
MU OF ASSYMMY: I V?
1)A7T •I 0 PEKF 1)14 HETI_
REDUCED PRESSURE C3AC KFrLOW PkEV H:M1'I' H:F! 'I'Fr $T RESUL'r*s'
AiR ]:YZ IrT VALVE
ClTF.f'K Y #Ir4
MLrF OFF VALVE 0
'D=1ZRNTT41� 5M FF
OkSEDTJi]EE':YES INOFRaKw.WP
C:Hl:i:K VAI.YI[IQ
5HLT MUT v_LT.,VEN3
CHECKYAI,
VALVE
QYI47AL TEST
CLOS 2f] TIS' VK,y (k
Cuj5ED T}OHT NO
C1�B� TTGFP: • �
PRF,5 � ME DRCROSS
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REPAIRS W Rkh
'OLP
�p - M A1' LD
*! SED
U EKMFBlf 37AHT75 AXP
FINAL TIM
OPENFI) AT ESLD
DROP ACR05S CHF.C.K vALvb
RE-pAM WHEN
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MEEI)EE?
CCrO�uu r�C�rr vra c�
FQ AL Tk7fi P
1 I1 -05M MHT. YO i NO
CU)SED T[CITT. Yr7i h+0
PRB&?«LSP AMOS8
CIPENTan AT
CSC& VALVE
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d 1
PRE'SSS KE VACUUM BREAKER ASSEMBLY BLY TEST RESULTS
AiR ]:YZ IrT VALVE
ClTF.f'K Y #Ir4
MLrF OFF VALVE 0
FALIDTOOPERYES:-%%
OkSEDTJi]EE':YES INOFRaKw.WP
IvrriAl-T&5T
OPENED AT FS3L.'•
ACTJMS CHECK VAf.VF. k1 _..y5jL7
I�t4DSEDTIGHT YESfN0
DEKR.lBE PARTS AND
-T
REPAIRS W Rkh
NEEDED
[:I;I[cMTIGHT -YIM NO PB�55L•kF
FINAL TIM
OPENFI) AT ESLD
DROP ACR05S CHF.C.K vALvb
CUOSED TECrHT: 1fE5 Wj
k P&M