2015_0706 C�ISCK ONE:
IRRIGATION � DOMESTIC � FIRELINE
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BACI�'LOW PREVENTION ASSEMBLY TES?AND MAINtENANCE REPORT
NAME OF PWS: t..-o�t��/I �►�Gt l�- �C�/��� ! L-E?S�"
PWS I.D.#
LOCATION OF SERVICE: `7t�� !r__d __��., �ri� �"�- ,�� ,
The bacl�flow preveation asscmbly detailed below has been tested and maintained as nquire� �, '1'N1�CC
reguladons and is cerdfied to bc operating within acceptable parameters.
TYPE OF ASSEMBLY
�+ Reduced Pressure Principle ❑ Pressure Vacuum Breakcr
❑ Double Chcck Valve o Amaosphere Vacuum Breaker
Maaufacturer �'������ Siza ��
Model Ivumbtr _�Q� �c: Located At ��Q /71��
Scrial Nimnber �`1_L.�L4-�� �'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Asaembly
lst Check 2nd Checl: Re(ief Valve Air Inlet Check Va1ve
Inical Test DC-Closed Closed Ti;ht o eaed at Opened at esid
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,�; Ti�.it/ � [�tf Leal:ed o � � psid �_osid
����� ��=�sid �
Did aot Open ❑ Leaked o
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and
Materials
Usod
Test ARer DC-Closed Closod Tight o Opeaed at Opcaed at _�sid
�P� T�� � __sDsid __nsid
RP sid
The above is certifiod to be true.
Firm Name �� ° �f -�-S� Certified Testa� �� � 1�°�'1
Firm Addrcss j✓' Ccrt. Teste No. Date�,-
;� Gauge # ��d Q�t,i
llate last accuracy tested � l�
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy
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