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CERT OF OCCU Dr n vc'/ .,a aP �" n 16700 E SecretariatFL. 37 ��� Loxahatchee, FL. 33470 1",• PLUMBING LLC. 7:?.. (561) 232-1887 are E.rr*rrcr fuer/.5/'a far MLat,'76245 ,rr CFC1429483 �/ /[ f/3 rG�bJ`t BACKFLOW PREVENTION ASSEMBLY FIELD TEST REPORT Customer Name: WoL err-o1 //vwot,r.- • Phone: Passed Street Address: 112 QW II AVe Rti trout 2a-ell,Ft 33 ¢ 3.- Failed NeDevice Location: Ei8Lrs,deor.Tpe NQuSQ Account No: Replaced Manufacturer: A f o l/O Model: PV© '-1 A Serial No: )3/ 17C 9 Meter No: Meter Reading: ,r ` Isolati:on o Containment o R.P o D.0 $P.V.B o A.V B Size: / Line Pressure: SC PSI . Test Date: oe/a 1/4-02-0 Check Valve #1 Check Valve #2 Differential Pressure Vacuum Pressure Relief Valve Breaker 1. Closed Tight o 1.Closed Tight o Opened At PSI Air Inlet Initial 2. Leaked o 2. Leaked o Opened 'I- O PSI 3.Gauge Pressure Across 3.Gauge Pressure Across Test Check Valve PSI Check Valve PSI Did Not Open o Did Not Open o Cleaned Only ❑ Cleaned Only o Cleaned Only o Check Valve Leaked o °, Held At /• 6.0 PSI Replaced: Replaced: Replaced: Rubber Parts Kit o Rubber Parts Kit o Rubber Parts Kit o Cleaned Only o C.V.Assembly o C.V.Assembly o R.V.Assembly o 14 OR OR OR Replaced: et Disc o Disc o Disc ❑ C.V.Assembly o rai 0-Rings o 0-Rings o Diaphragm o Disc Air Inlet o CC Seat o Seat o Seat o Disc C.V. o Spring o Spring o Spring o Spring o Stem/ Guide o Stem/Guide o Guide o Retainer o Retainer o Retainer o 0-Rings ❑ Guide o Lock Nuts o Lock Nuts o Other o 0-Rings o Other o Other o Other o Diff. Pressure Across Diff. Pressure Across Opened at PSI Air Inlet PSI Check Valve PSI Check Valve PSI Reduced Pressure Check Valve PSI All Repairs/ Replacement Shall Be Completed Within Ten (10) Days. Remarks: I hereby certify that this data is accurate and reflects the proper operation and maintenance of the unit. Initial Test By: '0'ro)& Le 2 COu-0 Certification No: /0// Exp.Date: 02/28/2 Repaired By: Certification No: Exp.Date: Final Test By: Certification No: Exp.Date: