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SS: CITY/ZIP: LOCATION: SERVICE TYPE: MANF: SIZE: MODEL #: SERIAL #: INITIAL/FINAL TEST INFORMATION: METER #: DEVICE #: ACCT #: F/S METER READ: SUPPLY PRESSURE: Reduced Pressure Principle Assembly Pressure Vacuum Breaker Double Check Valve Assembly Check Valve #1 Diff Pressure Relief Valve Check Valve #2 Initial Test Closed Tight: Initial Test Apparrent (psid): Opened (psid): Closed Tight: Did Not Open: Did Not Open: Leaked: Opened (psid): Fouled (psid): Open: Leaked: Initia.

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