2011_0426K ONE:
CATION
DOMESTIC
FIRELINE
BACKFI.OW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: ��; � �� � ����`
The back[low prevention assembly detailed below has been tested and maintained as rccluired by TC'EQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
,o Reduced Pressure Principle � Pressure Vacutmi Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer ��� GC _ � Size � ���
Model Number `� S -_�, Located At ' �"YJ� /�a2'
�-� c
Serial Number �i � -- /`-'`_ -��c��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRFAI.'FR
Double Check Valve Assembly
1st Checl: 2nd Cbecl: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at nsid
Ti�� Leaked a psid nsid
RP -nsid � X11
Leaked � Did not Open o Leaked o
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight a Opened at Opened at nsid
Repair Tigit[ o nsid nsid
RP std
The above is c /ertifi�ge�d to be true. -' '_. '1
Firm Name G��l �.)��� � i° �,�'' � Certified Tester / � _ _ � ��/ t—' J� �-' T-J'� � 6`�
Firm Address � ��d b C r- � ��iz�'� -> Cert Teste No. � ��'� %.�� S� _Date i� c'� �1
Gauge # _� � 7 °� �_ -Z( `- L?�i -'r �7 ✓zt c=v
llate Iast accuracy tested (� —1 �(- -CL}