2011_0628 (8)CIIEC,K ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by "i'CGQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduc -.d Pressure Principle � Pressure Vacutmm Breaker
O Double Check Valve � a•*• ---- -� -- rum Breaker
Manufacturer � � r„/LS
�( u-iE C �-��
Model Number T\ M `� _�� �� �P�� r
Serial Ntmmber '—� � S S C �j(J`C -� ��
a - � �
REDUCED PRESSI . I ��—� �/�t- � �- �r �� L� � ?VACUUM BRF'as.'F'R
Double Check Valve �G ' Yyl�, ,�,n��/V�U
1st Chekl: 2r l iG '� � i'� � "" �� �5 Chec3c Valve
l �
Initial Test DC- Closed Cl � i.1.�5� O� 5 � � __ nsid
Tigbt o Le ��
RP- nsid
Leaked o �w - 53 -fj' �2�G % _ -�. �.ycn O Leaked o
Repaus
and
Materials
Us«i
Test After DC- Closed I Closed Tight o I Opened at I Opened at I nsid II
Repair Tight o nsid nsid
RP nsid
The above is certified to be true.
Firm Name Certified Tester
Firm Addtsss Cert. Tests No. Date
Gauge #
Date Iast accuracy tested
White — Customers Copy Yellow —City Copy Pink — Tester's Copy