2011_0629CHECK ONE:
IRRIGATION
` DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
7-
NAME OF PWS:
PWS I.D. #
141 S,
LOCATION OF SERVICE: AA�-,& M
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The backflow prevention assembly detailed below has been teste n mamtait(e ? as require�5 d by� EQ
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number )sC
Serial Number T_ 7/9 Z&
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size - /
Located At N 14 % �
b� ~
The above is certified to be true.
Wright Baddlow & Plumbing
Firm Name .1515 NTown E Blv. Certified Tester
Sui6e 13"" �j
Firm Address 7X75150 Cent. Tester IPo S� Date
17 Z- 34-0Z
Gauge # ( 5 � 19 2-�_
Date last accuracy tested 3-
White - Yellow - � Pink -
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REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
al Test
DC- Closed ,
Closed Tight-,Zr'
ight
Opened at
Opened at
psid
f f y
Tilt
Leaked C3
sid
nsid
RP -_psid
` �p
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Wright Baddlow & Plumbing
Firm Name .1515 NTown E Blv. Certified Tester
Sui6e 13"" �j
Firm Address 7X75150 Cent. Tester IPo S� Date
17 Z- 34-0Z
Gauge # ( 5 � 19 2-�_
Date last accuracy tested 3-
White - Yellow - � Pink -
n
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