2015_0409 (3) CIIECK ONL': � � z
IRRIG ATION ll0 M ESTIC FIRELIN E
BAC�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REpORT
NAME OF PWS: ��1'4 c'r� (r.eue Il
PWS I.D. #
LOCA1"ION OF SERVICE: ��1� In�D k� 1��4 �y�y S• �Cl��ine �d •
�°P��� '�x• 1s419�
The backtlow �re��ention assembly detailed below as been tested and �naintained as required by TCE�)
regulations �and is certified to be opera�ing �uithin acceptable parameters.
TYPE OF ASSEMBLY
� Reducrd Pressure Principle ❑ Pres�urc Vacu�Breaker
❑ Double Check Valve C Amoospherc Vacuum Breal:er
Manufact�er �"��k►� Size ���
Model Iv�ber �7 S Locat�d At �'Ser (bo�n
Scrial Nimiber A 6 i�5 �5?�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Chec1: 2ad Checl: Relief Valve �r Inlet Checic Va]ve
Ininal Test DGClosed Closed Ti;ht � O�ened at Opeaed at _nsid
p,,3S Ti�t � ❑ Lcal:ed� � -l•� psid osid
f ti R.P-�psid
Lcai:ed ❑ �� Did not Opea ❑ L.cal:ed ❑
�P�
and
Mataiais
Uscd
Test ARer DC-Closed Closed Tight o Opencd at Opcaed at nsid
Rcpair Ti,ht ❑ �osid osid
RP sid
The above is cerrified to be trve.
Firm Namc �11 Te3� Cereifiod Testa w+11�4�n �o�dan
Firm Address �5� nar �n Q�l , n � Cat Testc No. � G Date � -G�l�
F�• wor�� • '6a�I�
Gauge # �j S►31615
llate last accuracy tested ��� IG � ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
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