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PERMIT DOCUMENTS u - • Al CERTIFIED CFC049415 1 7 - �` c F Al CERTIFIED BACKFLOW, PROTECTION, INC. 041 � � 1319 Central Terrace • Lake Worth, FL 33460 (561) 586-9020 • Fax (561)'547-4298 ] f I t 1 UTILITY 13n( i VI T'O Y'{ DATE OF TEST I NAME OF PREMISE: la avv1 ,73-0 r+ —Sri i r1 Ci —7 — A 1 -STREET ADDRESS: ILt1S Go Wo{`�{ VDI LOCATION OF DEVICE: IN . e �1 Ci r L- t/I 2A do7 E SKI'd c1 ' U 3324513 Size: 2." Manufacturer: t.l)1III,W Model: c� 7 s 11 XL Serial ca-RP , a El DC c IDPVB LIAVB ❑ AG METERNUMBER: 531 k 1 5� 0 ACCOUNT NUMBER: PRE'SSURE DROP ACROSS FIRST CHECK VALVE r LI PSI LINE PRESSURE it PSI . . •'*' CHECK VALVE#I CHECK VALVE/42 DIFFERENTIAL PRESSURE PRESSURE VACUUM '• 14 2.. ."1 RELIEF VALVE BREAKER I.LEAKED 0 1.LEAKED ❑ OPENED S ,IILBS. AIR INLET NinaOPENED AT PSI T m- 2.CLOSEDTIGHT4& 2.CLOSED TIGHT JR..- DID NOT OPEN ❑ DID NOT OPEN 0 CLEANID ❑ CLEANED 0 CLEANED ❑ CHECK VALVE: PSI SPLA®; REPLACED: REPLACED: LEAKED ❑ _E RUBBERPARTSKIT 0 RUBBERPARTSKIT ❑ RUBBERPARTSKIT 0 • E CV:ASSEMBLY ❑ C.V.ASSEMBLY ❑ RV.ASSEMBLY ❑ CLEANED 0 • OR OR OR REPLACED: ❑ A. DISC 0 DISC ❑ DISC ❑ RUBBERPARTSKIT ❑ I 0-RINGS ❑ 11•wives ❑ DIAPHRAGM ❑ CV.ASSEMBLY ❑ R. • SEAT ❑ SEAT ❑ SEAT 0 OR $=• SPRING 0 SPRING ❑ SPRING 0 DISCAIRINLET ❑ STEM/GUIDE ❑ STEM/GUIDE ❑ GLIDE 0 DISCCV. ❑ • RETAINER ❑ RETAINER ❑ 0-RINGS 0 SPRING ❑ LOCK NUTS ❑ LOCKNUIS ❑ OTHER ❑' RETAINER 0 OTHER 0 OTHER ❑ GUIDE ❑ O-RING ❑ Ol7i0t ❑ FINAL CLOSED TIGHT 0 CLOSED TIGHT ❑ OPENED AT LBS SATISFACTORY 0 TEST • PERMITNUMBER: FXISTING DEVICE: NEWINSTALLATION:A _ NOTE:ALLREPAIRS/REPLACEMENT SHALL BE COMPLETED WITHIN TEN(10)DAYS, t REMARKS: I i)11 1c wi ©I"7 S XL 7? — u 3-3201 )Le 1nl 4 wl UJo4 T Tl So, v11 1 - 7 '' - -2,1"2,01% S I HEREBY CERTIFY THATTHIS IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OFTHE UNIT. EXPIRATION DATE OF Al CERTIFIED BACKFLOW PROTECTION INC. TESTERS CERTIFICATION S ^7 MO DAY YR 3 INITIAL TEST BY 6�C -n-alfrA CERTIFICATENO. G.--1 t 12 t Z 3l CC REPAIREDBY DATE MO I DAY YR FINALTESTBY CERTIFICATE NO. LL