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�ff , Sta1e Form 5576a (2-35)
, "• INI71AiJA CJ�PARTMENT OF Et�ViRONMENTAL MANFtGEM�IST
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7HIS FORIVJlS TQ BE' COMF'L�T�D BYAN 11VIJIANA C�RTIFi,�'D 6ACK�LOW7'�S.T,�R.
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1. Customer name��. S 2. Customer campany ��- �C' � 1� t� 4 r�
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3, Custamer address r�umberand s,�frjeef, ci( , state, and Z!P code �, !� O
i�3�.�,' /V y P t �,n � i�t��A� f'S `7 �Z�
4. �acation of device (and address if differ�nt fram cusfomer) 5. ls ihe evice a new assembiy7 ❑ Yes � No
7�� pytg-C✓ Re lacin s�rial numher:
6.Type of s ice 7. Type af assembly
PDosnes#ic ❑ Fir� ❑ frrigatian �RP ❑ �C ❑ PVB ❑ SVS ❑ Air Gap ❑ AVg
a, Type of protecf'son �� 9. Serial number of device 3� ,� u�
❑ lsalation L`� Cantainmeni
10. Siz� of device 11. [tillanufacturef of device 12. Mod�l numE�er of device� L
� i� �t���1.5
13, Additior�al infnrmation (optronalJ
RP
Check Valve #k1
Etti�ia!
Date fmml�uyy): Held at PSID
Time:
� ❑ Closed `�ight
❑ PA55 � Leaked
❑ FA1t,
Final
[7afe �mm�ddyyl:-.�'ZL- O ��id at �d•4P51D
Time: l0�10..,� .
❑ Closed Tighi
�ASS - Cf LeaEced
❑ �AIL.
All� CAi'
Measured ver#[cai inches above o�erflow rin� :,
'�5. Comments
Check Val�e #2
Neld aE PS1D
❑ Closed Tight
❑ l.eaked
PVB/SVg
Pressure Differeniial Air Inlet
Re4ief Valve
Opaned at �Pened at PSiD
�S�p ❑ []id Hot Open
❑ Did Nat Open �h���Vaive Held PSIQ
He4d at PS{D Opened at �.d �Pened at PS4D
PSII] ❑ Qid [�ot Open
❑ Closed Tighf
����k�� ❑ l]id Nnt �pen Check Valve Helc€ PSI�
AlIB
size diameter.
Yes �1 h10
� 6. Name anci e-mail address of tesfer 17. Company name of tester (if applicahfeJ
fnitial .�g. Yelephone number 19. Signature and registration number ofi tester
Tesfer
2a. Testing equipment serial number 21. Tesfing equ'spment calibratian date (mmldd/yy)
22. t�a ai�d mail /a1ddress of fester /� 23. Company name of iesfer (if applicablej
Fi[lal A�1�1 vi� A�L rQ �` l� %�4o�9ti4 Q 5�'Y�.
2�4. Telephone n mber 25. Signature an registratior� numt�er of iester �� �� �S O� � Ol
Tesier �� - Q.. 4`�a �
26. Te�n eq�irme� serial number 27. Tesiing ec�uipme calibration date (mm/dd/yy)
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❑ By sigt�9ng this backflaw fest re�ort anc[ checking this bax, I hereby cert'sfy that I am familiarwifh #E�e i��forrnation confai��ed in
this form ar�d fihat to th� best of �ny know[edge and helief, suci� informafion is true, complete and accurate attF�e fime of the iest.
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