2013_0621 (7)C IIE'.CR ONE:
IRRIGATION
DOAIES'l'IC tyll FIRELINE
BACRTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS_ -
PIA'S I.D 4
LOCH T ION OF SERVICE: /� 1 /
1),I l: flow hrev --, tion a,,,, lhly detailed'heIovr ha,� hcen maintained as required by TCFQ
i'� lil4 ?til ll Milli !S �:Crtll ltd ti' he ol')eratlil`, t�lthlil l� l4�I1'i?�i { ;li'lillc "t I'ti.
n Reduced Pressure l';1rincipie
2P Deubie Check Valve
Manufacturer
Model Number QZl k% I
Serial Number A t f °I o 10
T P OF ASSr:��i
Pressure Vacuum Breaker
-- Atmosphere Vacuum Breaker
Size
1)U
Located At wee - 5i ,44- 6Y i'�
vev t "I
The above is certified to be true. / ,-- 5
Firm Name,& *-tL)%J C- ' -c-
Firm Address I C26 It
f'lC Xc- v1 G = c; ,
Certified Testa i ti r. Lc1 Az tti VI el",
Celt. Tester No. r S� / cL Date Lf;)Ilc:;Pp,[� j
Gauge # 1a0 &_ -4), 5'
Vate last accuracy tested �—
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy
i REDUCED PRESSLM- E PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Checks Valve Assembly
jIst
Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
I.r.itial Test
DC- Closed
Closed Tight W
Opened at
Opened at
•_ vsid
Tight i,
Leaked l
asid
nsid
Leaked
Did not Open co
LCaked G
Rep. airs
f
j Materials
E used
Test :after
DC- Closed
CIosed Tight o
Opened at
Opened at
aSid
Repair
Tight ❑
asid
aSid
RP sid
The above is certified to be true. / ,-- 5
Firm Name,& *-tL)%J C- ' -c-
Firm Address I C26 It
f'lC Xc- v1 G = c; ,
Certified Testa i ti r. Lc1 Az tti VI el",
Celt. Tester No. r S� / cL Date Lf;)Ilc:;Pp,[� j
Gauge # 1a0 &_ -4), 5'
Vate last accuracy tested �—
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy