2011_0401CiiECK ONE:
IRRIGATION DOMESTIC
FIKELINE ,
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. # "
LOCATION OF SERVICE: �' �� � - E _ ' %'
The backflow prevention assembly detailed below has been tested and maintained as required by TC,E(2
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduc�i Pressure Principle � Pressure Va�-+�•**� Breaker
" Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer ��-'f -i-- -5 Size "�
Model Number � � y Located At `'�F� =1 �' °- 7
serial Number � / b! 3 � -- ria � 7
The above is certified to be true, i � x-15
Firm Name Q S s �.'Q es, i,+n �Cx r1 Certified Tests � ;� . , � � _ i- t� *'�'
Firm Address � � � � .J � � L «2 � t� �C � Cert. Tester No. �.���'1,.c� ,3 i ?� a^; Date `7',i ; '; f °i'
Gauge # � / Cj y y
Date Iast accuracy tested f — 3 � - / �
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'FR
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ,,
f.: -_
Closed Ti�h`t ®'�
Opened at
Opened at
nsid
Tilt � • -� �
Leaked D
nsid
nsid
RP- nsid
Leaked D
Did not Open O
Leaked D
Rap airs
and
Materials
Used
Test Auer
DC- Closed
Closed TiQ -,ht o
Opened at
Opened at
nsid
Repair
Tien[ a
nsid
nsid
RP sid
The above is certified to be true, i � x-15
Firm Name Q S s �.'Q es, i,+n �Cx r1 Certified Tests � ;� . , � � _ i- t� *'�'
Firm Address � � � � .J � � L «2 � t� �C � Cert. Tester No. �.���'1,.c� ,3 i ?� a^; Date `7',i ; '; f °i'
Gauge # � / Cj y y
Date Iast accuracy tested f — 3 � - / �
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy