2015_0714 (2) C�IBCK ON�-
IRRIGATION DOMESTIC rf FIRELINE
�� BAC'I�Z.OW PREVENTION ASSFNN�LY TES'T AND MAII�iT'ENANCE REpORT
NAIv�OF PWS: �D e I�+-i� h �G�o� �
PWS I.D. #
� Par kct�.�ay
LOCATION OF SERVICE: t �� UV�
The bacl�low preveation asscmbly detailed below has bxn tested aad maintained as required by T'NRCC
regulauons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�C' Reduced Pressure Principlo o Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Maaufacturer (�.�Ct�'-�- Sizc ���
Model Number aQ�1 Y�� � Located At W�T ��Z-Z
Serial N�ber ��`�� I O
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAKER
�� , Double Check Valve Assembly
�
lst Check 2nd Checl: Reiief Valve Air Inlet Check Valve
InidaI Test DC-Closed Closed Ti�ht o Opeaed at Opeaed at _nsid
Ti�t ❑ Lcal:cd o Z, Z �sid __�nsid
�p��5 RP- �� sid
Leal:ed 0 Did not Open O I,eaked o
Repairs
and
Materials
Used
Test ARer DC-Closed Closed Tight ❑ Opeaed at Opeaed at __nsid
Repair Tight ❑ _flsid __�osid
RP sid
The above is certifiod to be true.
(1 � , r �
Firm Name �-O,�Q f I� �S� Catified Tesce ! a�r G� � �
Firm Addc�s,s 3 D 3 P Q n � �,r Cat Testc Na �S Date
t �
�'�`°� Gauge # �Sf�C�bO
�_._� � '
llate last accuracy tested 7 /
White- Customer's Copy Yellow - City Copy , Pink-Tester's Copy
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