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653_0001.tif i AC _S C 0ot,18. 2012 4:25PM JETTER'S PLUMBING 402 721 3013 No.6686 — P. 1 68025 i Fremont Department of Utilities - 3000 E. 1st Street, Fremont, NE M Telephone: 402 - 727 -2613 FAX: 402 -727 -2675 MUST BE TYPED OR COMPLETED IN INK Contact Person Nante of pacility Address ofcontactperson Facility Address �� city, State, Zip f City, State, Zip Location or Device � Scriaf No. � � L � � � Modal Na. �e f Sizo Device Type JJ �, ry Manuracturorr _ ' po t) TJ /� (-✓� YJr qq s d 7PSID TE: G� tT fa 2C7�2 For Double Detector Line Pressure at Time of Test (at inlet test cock) w Installation? Double Check Valve Assemblies only. I A} Yes No ❑ Meter# A. Pressure Loss Across First Check Valve places: ke: B. Relief Valve Opened at B} del #: Reading C. Difference (A-14) I) PSID Serial #: Check Valves Air Inlet Differential Shut Off Valves #I #2 Pressure Vacuum Breaker Pressure Relief Va� #i #2 Pressure Loss Opened at Opened at INITIAL - 3 1. Leaked C) —� A) E) 2.2- PSID F) PSID Leak ed G) ❑ El TEST 2. Closed Tight ❑ ❑ 2. Closed Tight ❑ ❑ Did Not Open ❑ Did Not Open Protection Typ ❑Boiler © ChcnI ray Lab El Dental E] Drink Dispenser ❑ Fire S prinkler Sys t. ❑ Ice Machine Lawn Sprinkler F mortuary Hazard Type: p ❑ Low High ❑ Service Contain, ❑ Swim Pool /Hot Tub [3 utility Rootn/Sink El Other CheckVa{ves Air[nfet Differential Shut Oft Valves #1 #2 Pressure Vacuum Breaker pressure Relief Valve #I #2 Pressure Loss Opened at Opened at ❑ F­1 FI) FINAL PSID 1, Leaked G) ❑ F-1 1. Leaked C) b) F) PSID F) TEST 2, Closed Tight 2. Closed Tight El ❑ E-1 � ❑ en Did Not U � ❑ Did Not Open p REMARKS: Date of Testing Initial Test performed by: Company (Print) jeeed- 0 - - - - -- Cert.No, t" - - - - -� n �- -- - " - - ' - J«C Si Exp. Date ( Signatur e ) ) Company Date of Repair Repaired by: j (Print) Cert. Na. ( Signature) - ° Exp. Date Date of Testing Final Test performed by: Company i (Print) -- Cert.No. (Signature) Exp. Date �I I