2012_0312 (3)CiIECK ONEa
IR RIG ATION__� D O M L'S'TIC FIR F.LINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L � ? �� L'r F' Lc >,�P.� -t.�
PWS I -D. #
LOCATION OF SERVICE: ��� /1 ��'Z..�.z= IJ.i
Thu bac!<Ilrrw l�ruvcntion assembly detailed below has been tested atnd maintained as required by TCFQ
ru�ulations and is certified to bu operatin�; �� ithin acceptable parameters -
TYPE OF ASSEMBLY
Reduced Pressure Principle a Pressure Va�-+�***+ Breaker
Double Check Valve � Ammosphcre Vacuum Breaker
Manufacturer F'G b < <� H
Size �
Model Number � Located At
Serial Number � 0�� % S- L �c> /� � �
The above is cearti£xed to be true- �/-PS
Firm Name ALTr �•J �l �-c Certified Testa � -
Firm Address Qd QO � 7 � % Cent Testa No_ -� � Date 3/ /�� /
Gauge # ���/ �'/ �O
llate Last accuracy tested/ /
White - Customer`s Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRLTICIPLE ASSEMBLY
I PRESSURE VACL -iJM BRF'a�'R
Double Check V alve Assembly
1st Cheri:
2nd Cbeci:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tight /• � »
Leaked /- g o
nsid
nsid
RP- nsid
Leaked C
Did noc Open Q
Leaked D
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Repair
Tight a
vsid
nsid
RP sid
The above is cearti£xed to be true- �/-PS
Firm Name ALTr �•J �l �-c Certified Testa � -
Firm Address Qd QO � 7 � % Cent Testa No_ -� � Date 3/ /�� /
Gauge # ���/ �'/ �O
llate Last accuracy tested/ /
White - Customer`s Copy Yellow -City Copy Pink - Tester`s Copy