2011_1129 (3)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE_,^K,2_
BACIGLOW PREVENTION ASSEMBLY TEST AND MAUMXANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backtlox� prev ention assembly detailed belov� has been tested and maintained as required by "I'('EQ
regulations and is certificd to be operating �v ithiri acceptable. parameters.
TYPE OF ASSEIvfBLY
G Reduced Pressure Pn=ple D Pressure Vactrurn Breaker
❑ Double Check Valve c Atmosphere Vacuum Breaker
X' pc OA
Manufacturer LJ c,Tr5 Size
Model Number '77 -/ X Located At -r Serial Number I Cull 7 3 U 410 a
REDUCED PRESSURE PRINCIPLE : ASSEMMLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check: 2nd Check: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight 0 Opened at Opened at __nsid
Tisfit g, 0 Leaked 9,U ❑ �psid _ ^osid
RP -„ psid
Leaked ❑ Did not Open ❑ Leaked o
Repairs
and
Materials
Used
Test Ainta DC- Closed Closed Tight ❑ Opened at Opened at _ nsid
Repair Tight ❑ nsid osid
RP sid
The above is certified to be true.
Firm Name /} L rr ��,i C � rz Certified Testa _1J i J c -r z r- W e-AA -t
Firm Address P o R,,? 7 92 Cat. Testa No. 6P0051-2 i a7 Date il Id 9 �(
14)r—x G Vt c &J , e-
Gauge # 3a y 5 18,
Date last accuracy tested 571/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy