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2021.12.02 - Atlantic Village Medical @ 1029 Atlantic Blvd - 2 in, M#919QT, S#37091 - sBACKFLOW ASSEMBLY TEST REPORT City City Device Type: Mfg:Model No. Check Valve # 1 Diff/Prsre ReliefValve Check Valve # 2 Prsre Vac Break Opened at Air Inlet opened at LBS. Did not Open Did not Open Closed Tight at Remarks: (Signature) Customer Account Number: Water Utility Co. DCDA RPDA Service Type Test Results Initial By: Repaired By: Final by: Commercial/Residential Meter # Location: SCAN # Size Leaked Leaked Customer Name:Customer Contact: Service Address:Mailing Address: State State Closed Tight at P.S.I Final Check Valve # 1 P.S.I Closed Tight at P.S.I Final Check Valve # 2 P.S.I Relief Valve LBS P.S.I. P.S.I. Tech Name Affiliation Certification Test Date I HEREBY CERTIFY THAT THIS DATA IS ACCURATE Serial Number Final Test Results DC RP Zip Gauge Company