2013_0621 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE w
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
N CE OF PWS: `l t 0 1)
PIXS , D, u
LOCATION OF SERVICE: li � I 5• 120 y _ L
The hack slow I)rev cr,tjon assembly det=ailed helo� has teen ?�:-,led and maintained as required by TC EQ
[� iil� "tt.elil> aald 1, e:Cllllied t,' he Oreratink' \dahlia acceplahlc i_t ?amtlCrti.
C : Reduced Pressure Principle
,J Doubie Check Valve
Manufacturer LL)C/'t 5
• s ass
Serial INimiber [ J I
TYPE OF ASSEMBLY
C, Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size 31W
Located At S .I c uc,� t
i
The above is certified to be true. I-e 5
Firm Name AC Tw),,1 C► -'-
Firm Address PC) 66 :2 r. 3
Gauge
Certified Tests L Oald wk 142 *- "0 e✓"
Cat Testa No. jg4n q, / c)' _ Date 6 1d i &
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
i
i
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
7C- Closed
Closed Tight ;V
Opened at
Opened at
nsid
Tilt c2 .0
RP- �____psid
Leaked G
�pSid
t?Sid
I Reaairs '
Leaked C
i
E
Did not Open G
Leaked G
and
Materials
j
i
i
Used 1
j
Test After
DC- Closed
Closed Tight a
Opened at
Opened at
nSid
Repair
Tight ❑ '
asid
nSid
RP sid
The above is certified to be true. I-e 5
Firm Name AC Tw),,1 C► -'-
Firm Address PC) 66 :2 r. 3
Gauge
Certified Tests L Oald wk 142 *- "0 e✓"
Cat Testa No. jg4n q, / c)' _ Date 6 1d i &
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy