2014_0328 (3)Do I ESTIC FIRELINE
3"J71CIFLOW PREVENTION ASSEMBLE' TEST AND MAINTENANCE REPORT
FIXS LD.
01- � 710-IN, OF SERVIcr:
Ir � IC
R--duc-ed?rtssure - mc,6
Dcubic Check 'v.-Ive
Manu acrar-.:- bLAInif�
Model, N=ber 7 0 CM
Serial N=bt.-
i� !,�, -, ; - I -, i-equit-ed by TC EQ
-I �!rd a,, I
\6illM,
-r�YPE OF ASSEIMBLY
I
Pressure Vac= Breaker
Atmosphere Vacuum Breaker
Size
Locate
,d A-
REXCED PRESSURE PRINCIPLEASSE.N[BLY
PRESSURE VACUUM BREAKER
Double Che-cic Valve.Assemblv
ist Check -nd Check- Relief Valve
-Air Inlet
Check Valve
laical Test
I DC-Closed Closed Tight
Opened at
Opened at
psid
Timir 3 M-1- Leakcd
-;
_psId
sid
Leaked
Did not Open
Leaked
Rep a L rs
and
Marenals
used
es r Afar DC•Closed Closed Tight C3
Opened at
Opened at
--.psid
Repair TiQnt
--------psid
psid
The above is cm-t wed ,.'o be xue.
Firm Name A c4 t, �,,-4- P.,n
cn_ Cmtified Tes=
Firm Addr= (W757 �(44-4�rert Testa No. e�?*31—Datc
6 a uge 4 0 31 z -L
Date last accuracy tested 5--�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy