2011_1129CHECK ONE:
IRRIGATION DOMESTIC_
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: LIT' C' ,C 4 12
PWS I.D. # `
LOCATION OF SERVICE: r✓cC-
'The back- tlm� prevention assembly detailed be] im has been tested acid maintained as required by'l'(.'F.Q
1,c01.11atinns and is certified to be operatin-, Nt acceptable parameters.
TYPE OF ASSEMBLY
Q Reduced Pressure Principle C Pressure Vacuum Breaker
XDouble Check Valve c Atmosphere Vacuum Breaker
Manufacturer tocarT 5, Size
s
Model Number Ob -::2 1,yjI Located Ati<r -�,
c�
Serial Number
REDUCED PRESSURE PRINCIPLE ASSENIBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check: Relief Valve Air Inlet Check Valve
Ininal Test DC- Closed Closed Tight AV Opened at Opened at nsid
Tight Leaked �. j ❑ _ sid osid
RP- _psid
Leaked O Did not Open O Leaked O
Repairs
and
Materials
Used
Test ARrar DC- Closed Closed Tight o Opened at Opened at ,_ nsid
Repair Tight o __�- .__,osid
RP sid
The above is certified to be true. Y-e 5
Firm Name A L? c i) , )_(�; 1e Certified Tester
Firm Address PO G u 7 S 7 Cat Tester No. B G_ , �I ?'% Due � t
()C-XC I'icCh -C
Gauge # 3 d -1 c, i,v
Date last accuracy tested / �L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy