2011_0531 (8)CIIECK ONE:
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD_ �
LOCATION OF SERVICE: �= �-
The backflow prevention assembly detailed below has been tested and maintained as required by TCE(2
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
D Reduced Pressure Principle D Pressurc Vacuinn Breaker
Q, Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Nimmber
The above is certified to be true.
Firm Name • uGi t' -i v L�
Firm Address -�� t',�[ ' '� ✓P iT
Gauge # � 7z / �'
Date last accuracy tested
Certified Tester
Cent Tester No. - � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACWM
BRE_A�R
Double Check Valve Assembly
1st Chec1:
2nd Chec3:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closcd
Closed Tight :�.
Opened at
Opened at
osid
Tilt C3;
Leaked a
psid
osid
RP- osid
_
Leaked �
Did not Opea a
Leaked a
Rcpaus
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
Firm Name • uGi t' -i v L�
Firm Address -�� t',�[ ' '� ✓P iT
Gauge # � 7z / �'
Date last accuracy tested
Certified Tester
Cent Tester No. - � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy