2013_0621 (4)C: IFCK ONE:
IRIUGAI'I€:tN DUMESTIC: FIItELINE IV
BACKTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PA'S 1.^.
LOCATION OF SER"v"ICE: /J d 5..
lh� h;irh:fluvy rre�cntion a'sticmilk tletttilcd below ha" them anal maintained as required by TCL'Q
fie ���?erA. " v� ithi11
- Reduced Pressure Principie
Ruble Check Valve
(4lanufaC:3rrer bjC% `r
Model Number
Serial Number 10 0 1 7.5
TYPE OF ksSEi4fBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
E/
size v
Located At W 5rdc uQ( tC .4). 0r Pi Mn Oex-,,A
The above is certified to be true. I-e 3
Firm Name A r-10 j (7, ---
Firm Address PO 66 r i S
(,,t r—xC vy C- C
Gauge # _L2)_3tQaca?A�'
Certified Tester L WC.y N L2 � vi w t----
Cert. Tester No. / c7 ` Date 61C)I & 3
oate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
I REDUCED PRESSURE PRINCIPLE ASSEMBLY
i PRESSURE VACUUM BREAKER
Double Check Valve Assembly
j
�!
1st Check
2nd Check
1 Relief Valve
:fir Inlet
Check Valve
I
Initial Test
DC- Closed
Closed Tight /Q'
Opened at
Opened at
nsid
Ti -t 3 �s
Leaked y
nsid
psid
r2.p- _,.._._psid
Leaked t=
Did not Open O
Leaked G
Re=3Ir5 i
and I
Materials I
i
Used i
!
Test After
DC- Closed
CIesed Tight O
Opened at
Opened at
nsid
Repair !Tight
e�psid
nsid
RP sid I
The above is certified to be true. I-e 3
Firm Name A r-10 j (7, ---
Firm Address PO 66 r i S
(,,t r—xC vy C- C
Gauge # _L2)_3tQaca?A�'
Certified Tester L WC.y N L2 � vi w t----
Cert. Tester No. / c7 ` Date 61C)I & 3
oate last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy