2011_1021CIIECK ONE:
IRRIGATIO N DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE : / ' � `- ' ' ''
The back(low prevention assembly detailed below has been tested and maintained as required by TCE.Q
regulations and is certified to be operating within acceptable l��arametcrs.
TYPE OF ASSEMBLY
Q Reduces Pressure Principle D Pressure Vacu�mm Breaker
o Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true_
Fitm Name
Firm Address 3�On
Gauge #
Date last accuracy tested
Certified Tester ,:`
Cent. Tester No. � - Date
W Rite — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.7i.7M BRE_A�'R
Double Check Valve Assembly
1st Cheri:
tad Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed _.
Closed Tight
`Opined at
Opened at
nsid
Ti�L D
Leaked o
psid
nsid
RP- nsid
Leaked �
-
� '�'
Did not Opm O
Leaked o
Repairs
and
MatcriaLs
Used
Test ARer
DC- Closed
Closed Tight [7
Opined at
Opined at
nsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true_
Fitm Name
Firm Address 3�On
Gauge #
Date last accuracy tested
Certified Tester ,:`
Cent. Tester No. � - Date
W Rite — Customer's Copy Yellow —City Copy Pink — Tester's Copy