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e! L:iry
11 }' OF CU, PILL
r� �h Cj'?
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LOCATION OF SERV r-- _ _ �� - —
_ ed as required by T1�ti CC
1h b O5v prev:o.+don zsse=bly aged n acc� � e p= � grid
re�anous nd is c,�ed to be oQera=c v�rsthsu °P
TYPE OF ASSEIOLY
D Eras= Va=n Breaker
Redricti pres=e Principle Atmosphere Vacuum Breaker
n Double Check Valve.
D
Size l
Manufactdrer V-111 e -7
!' Located.At _C.1 -1 l
Model Number
Serial N=ber.
REDUCED
PpSSiJ P11CPL ASEd.I' PRgSSiTI. VACUUM
BREAKER
Double Che&'Valve Asse�ly
fist Cbe:9� 2nd Chet: Relief Valve .far Inlet .
Cheek valve
at 1
al Test DC- Closed Closed Tight sid OP Sid
Inrn . L- -eahed D P
Tilt
kP -sid 2 _ Z Di
t Opp. p
Leaked .
PICPZ rs .
and
Matmials
Used ened.at
Test After DC- closed
Closed Tight o Opencd at Op
�,psia . �psid
gip k. Tight
RP_ --sid
The above is =dfied to be true.
Firm N== A�� Certifies �r
CatTestes No.
Date
I�
Firffi Add= ; G
Gauge
Date last accuracy tested �._ � . J4
Pl7fIk Tests=,T' Cu":%lOv