2013_0628 (4)CHECK ONE
IRRIGATION'
DOMESTIC-- FIRELINE,
7,
NA1E OF PWS- C 1 11 ".11, 1 )F , OPPELL
WSMIM
M IN W
Firm Ad -1
Cem Testa NA
Gauge
Date last accuracy tested
Wbite -- Customer's Copy Yellow —City Copy Pink — Tester's Copy
Double Che& Valve Assexnbl�v
Double
1st Check 2nd Check
Relief Valve
Air Inlet
Check Valve
est
X-Clos, 'Closed Ticht
Q,19
Opened at
Opened 3t
--------Psid
t/v
TI& Leaked
RP-_psid
Lcaked,
Did not Open 0
Ltak*ed
Rcpaks
and
Matelials
Used
I er
DC-Closed Closed Tight
Opened at
opened at
psid
zrcr
lzr'fight
Tip
LR
--------psid
psid
RP
P
Firm Ad -1
Cem Testa NA
Gauge
Date last accuracy tested
Wbite -- Customer's Copy Yellow —City Copy Pink — Tester's Copy