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2011_0505 (4)
CIIECIi ONE. IRRIGATION DOMESTIC FIRELINE BACKF'I.OW 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 TCEC2 regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY o Rtriuc, -d Pressure Principle � Pressure Vacutnn Breaker O Double Check Valve o Atmosphere Vacuum Breaker Manufacturer Model Number Serial Number Size Located At r� The above is certified to be true. Film Name _ Firm Address Gauge # llate last accuracy tested Certified Tester Cent. Tester No. Datc White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR��R Double Check Valve Assembly 1st Chek: 2nd Chekl: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight © Opined at Opined at nsid Tilt Ca Leaked � psid nsid RP- nsid Lcaaed o Did not Opm o Leaked o Rep airs and Materials Used Test After DC- Closed Closed Tight D Opined at Opined at nsid Repair Tight o nsid nsid RP sid r� The above is certified to be true. Film Name _ Firm Address Gauge # llate last accuracy tested Certified Tester Cent. Tester No. Datc White - Customer's Copy Yellow -City Copy Pink - Tester's Copy