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American Society of Sanitary Engineering <br /> Pressure Vacuum Breaker Assembly (PVB) <br /> ASSE Standard#1020.Eield Test Report <br /> a - <br /> Owner of Property <br /> Address LI 95 0 p t vl ry' <br /> r City OC-OniLI State Y\f\' Zip Code 5-32-3 <br /> Occupant of Property(if different from owner) <br /> Occupant Address <br /> r City State Zip Code <br /> t <br /> 0 Manufacturer of Device: c M del#: 6S <br /> Size of Device: 1" Serial#: \ f\ 'I V 14)7 c <br /> Location of Assembly and Equipment or System Application: S,og- c1C tie vA -, ei,r•cM Q► 1 <br /> Test Equipment: _ <br /> Manufacturer: f Q I�� Model#: --Luc o - /�- Serial #: O'1 Mit <br /> Calibration Date: ET I <br /> y <br /> Date test was performed: ;, Time test was performed: 1 .O 3 Static Line Pressure: <br /> 7 <br /> Air Inlet Valve Check Valve Shut Off#2 <br /> Leaking ( ) <br /> Failed to Open Closed Tight ( ) Leaking ( ) <br /> I Initial Test <br /> Opened at psid Pressure DropAcross <br /> Closed Tight ( ) <br /> li, Check Valve#1 psid <br /> Describe parts and <br /> repairs when needed <br /> Leaking ( ) j <br /> Opened atZ .0psid Closed Tight l S— Leaking ( ) <br /> Final Test <br /> Pressure Drop rossClosed Tighe <br /> Check Valve#1 . psid `� <br /> Certified Tester(print) ,.X..rtm_yZ Assembly Final Test <br /> Addresx l6I6 t -4\e . Performance <br /> City ' c:-0r. u,1 , State MN Zip ss-3-3l <br /> Phone#: L t--L L Pas <br /> License#: fGU-1'tbo) Certification# psse- -2-$OLIO Fail <br /> Signature 1,.1 Date: ()S /2.1114- <br /> Comments or Recommendations (continue to other side,if needed): <br /> Cross-Connection Control Professional Qualcations Standard 77 <br /> ASSE Series 5000-2009 <br />