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e' S 3226 CHERRY PALM DRIVE <br /> TAMPA,FL 33619 <br /> \"N/WAYNE qj 81 3-630-0303•FAX:813-630-0312 <br /> 11326 DISTRIBUTION AVENUE WEST 4683 LAREDO AVENUE <br /> JACKSONVILLE,FLORIDA 32256-2745 Automatic Fire Sprinklers, Inc. <br /> FORT MYERS,FLORIDA 33905 <br /> 904-268-3030-FAX.904-268-0724 222 CAPITOL CT. 239-433-3030-FAX:239-433-3263 <br /> 4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 NW 16TH TERRACE <br /> CONCORD,NORTH CAROLINA 28027 407-656-3030 -407-656-8026 POMPANO BEACH,FLORIDA 33064 <br /> 704-782-3032-FAX:704-795-6838 954-917-3030-FAX:954-917-9424 <br /> Backflow Prevention Assembly Test Report a <br /> CUSTOMER: �i��i \ ) ; 1 �D7 j� INSPECTOR: (_ '�i _ice DATE: 'al <br /> ADDRESS: 2Q0 .Z o l5'+l S^ LICENSE#: ✓" TIME: 0�.�0Crrr�t <br /> CITY,ST,ZIP: R �s 1 s(j Z ISC#: 6 3 09,2 <br /> JOB LOCATION: L <br /> ADDRESS: <br /> LOCATION(CHECK&DESCRIBE): (' INSIDE ABOVE GROUND ( ,, PIT USAGE(CHECK ONE): IRE Fj DOMESTIC <br /> (}DC +_, DDC (- DDC-BYPASS (-,, RPZ I(-, RPZ-DET RPZ-DET-BYPASS MFG MODEL SIZE SERIAL# <br /> TYPE(CHECK): i)k,n5 920 DR <br /> REDUCED PRESSURE PRINCIPLE ASSEMBLY YES al <br /> DATE I <br /> RELIEF PORTS ON RPZ FREE OF CONTINOUS DISCHARGE?(CHECK ONE) (`; NO INSTALLED <br /> APPARENT PRESSURE DROP DATE <br /> DOUBLE CHECK VALVE ASSEMBLY ACROSS FIRST CHECK VALVE REBUILT <br /> CHECK VALVE#1 CHECK VALVE#2 RELIEF VALVE PVB/SVB <br /> HELD AT PSID HELD AT PSID OPENED AT PSID AIR INLET <br /> OPENED AT PSID <br /> LEAKED rj LEAKED rl DID NOT OPEN F 71 <br /> E= <br /> z CLOSED TIGHT CLOSED TIGHT DID NOT OPEN <br /> CLEANED rl CLEANED F-1 CLEANED CLEANED <br /> w <br /> a REPLACED 711 REPLACED F-I REPLACED F7' REPLACED <br /> Q <br /> IL <br /> LU I <br /> z _ t PSID �r PSID AIR INLET PSID <br /> PSID <br /> aL CHECK VALVE PSID <br /> CLOSED TIGHT _ CLOSED TIGHT [—� <br /> ASS (1 FAIL SUPPLY PRESSURE PS <br /> METER#: �� G y� <br /> READING#: a v®�r✓ �� / ✓ 93 0 <br /> CERTIFICATION TAG ON BFP INSPECTOR'S SIGNATURE: BFP IN SERVICE <br /> i <br />