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2014_0703 CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: L / ? 1 l r lC PWS I.D. # f3©( 114/10104 �!i -i!I LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested and maintained as required by TC.EQ regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vac++++*+ Breaker Double Cheek Valve ❑ Atmosphere Vacuum Breaker Manufacturer X411 -1-1C Size " Model Number 0e) r Located At cSnl. fly met s-1- ter new- :Mfr Serial Number 4/09 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Cheek Valve Assembly 1st Cheek 2nd Cheek Relief Valve Air Inlet Cheek Valve - - — Initial Test DC- Closed Closed Tight Ile Opened at Opened at psid Tight Z., Z, Leaked z_ L3 ❑ psid _nsid RP- psi Leaked ❑ Did not Open ❑ Leaked ❑ Repair' epaus and Materials Used Test After DC- Closed Closed Tight a Opened at Opened at psid Repair Tight ❑ nsid psid RP nsid - n The above is certified to be true. Firm Name Ll � LAS Certified Testa �tia.ch Firm Address PO ! 74 / Cat Testa f i No. i / 49k.5i hate // yi 7 bk, atuliV c-h tat 7 si (DS Gauge # 04 1.007 Date last accuracy tested V6 /th White - Customer's Copy Yellow - City Copy Pink - Tester's Copy