2011_1005 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: = <-
PWS I_D. #
LOCATION OF SERVICE: i
The backtlow prevention assembly detailed below has been tested and maintained as required by'i'CEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle a Pressure Vacuum Breaker
CYr Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �if;:� t `. Size l`�
Modei Ntrrnber -75 -7 DC n A- (' V Located At =� � �`�< >, .-,.e r .� � �,:: -
Serial Number S C Z� O 3
The above is certified to be true.
Firm Namc
Firm Address
Gauge # �ZOSO1J�_
Date last accuracy tested
Certified Tcste
Cert Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTL7M BFZF'A�R
Double Check Valve Assembly
1st Chek3:
2nd Chekl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight Ct''
Opined at
Opened at
nsid
Tight C-3
Leaked o
psid
nsid
RP- ` • � nsid
Leaked o
Did noc Opm o
Leaked o
Repairs
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opmcd at
Opined at
nsid
Rtpair
Tight D
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc
Firm Address
Gauge # �ZOSO1J�_
Date last accuracy tested
Certified Tcste
Cert Testa No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy