2015_0706 C�IECK ONE:
IRRIGATION DOMESTIC � _ FIftELINE
BACI�LOW PREVENTI�N ASSEMBLY TEST AND MAINTENANCE
REPORT
NAME OF PWS: _�2��P I! ."�S� ��r�,n t ��-t ra�� �►°1
PWS I.D. #
LOCATION OF SERVICE: �0� � , L�E v1-��nr'� ��n
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13e bacl�low preveation asscmbly decaile� below has beea usted and m.aintaiaed as required bv 'I'NRCC
rcguladons and is ccrdfied to bc operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Brea�ker
,�i.�`` Double Check Valve o Atmosphere Vacuum Brea�er
►
Manufactiaer V`�-� S Size ��
Modei Ivumbtr 6 f7�1 YYl i �?T Located At . �►o�e
Serial Nu�ber I J � � ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BREAI�R
Double Check Valve Assembly
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lst Check , ?nd Checl: �, �ef Valve Air Inlet Check Valve
Inidal Test DC-Closed Closed Tight � Opeaed at Opeaed at _esid
Ti�t � Leal:cd O _�Dsid _,_osid
����j �-_�S�a
L,eati;ed 0 Dia noc Open � Lealced o
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aad
Mataials
Usod
Test After DC-Closed Closed Tight o Opeaod at Opmad at _�sid
Rapair Tight o _nsid _�osid
RP sid
The above is certifiod to be true.
Firm N �� ' � ,��
Cerrified TCStes �� n i J�r� � !
Firm Address � `✓ Cat Testa No. Date_�,�j'�
��` Ga e � � �
, "� C�C�C2 _
llate last accuracy tested � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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