2014_1006 �
C.�IBCK ONE:
IRRIGATION ,� DOMESTIC FIBELINE
BACI�LOW PREVENTI., N - ' LY TEST AND MAINTENANCE REppR?
� ) �
NAME OF PWS: GV 1 /l� LL� ►'��r?�'a
PWS I.D. #
LOCATION OF SERVICE: �0 S. C.�pcJel 1 ��.
The bacl�low preveation asscmbly detailed below has been tested aad main�ain� � nq� �, �CC
reguladons and is cerd5ed to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Press�e Principle o Pressure Vacuum Breaker
,'� Double Check Valve ❑ Atmosphere Vacuum Brealctt
C 1� ��
Maaufacturer 1'��J 6� Size Z
Model Number �S C� Located At � �a� o� /-t �-�4�I
Serial N�ber �� ��U�-I 3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACiTUM BREAi�R
Double Check Valve Asaembly
lst Check 2•3 2nd Checl: Z � �ef Valve :a►ir Inlet Checic Valve
Inival Test DC•Closed Closed Tight � Opeaed at Opened at _esid
Ti�t 1� Leal:cd ❑ nsid __esid
�Q,�� RP-__psid
Leai►ed ❑ Did not Open o 1,ealced ❑
��
and
Materials
Used
Test Aftnr DC-Closed Closed Tight o Opened at Opeaai at nsid
Repair Tight � _�osid _,_osid -�
RP sid
'Ibe above is catifiod to be true.
Firm Name� � -$--�L� R Certified Testa�¢ � �I
; D n� �� �
Firm Addras � r. Cat Test�No.
Gauge � _
llate last accuracy tested ��
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy