2015_1009 C�IBCK QNE:
IRRIGATION ✓ DOMESTIC FIRELINE
BAC'I�LOW PREVENTION ASSF.N�LY TEST AND MAINPENANCE REppRT
NAMEOFPWS: P�£'I� �� � C� m, ���
PWS I.D.#
LOCATION OF SERVICE: `+�� � �C�
The bacl�low preveation asscmbly detailod below has bem usted and ma�nra�n� � nq,� �, �CC
reguladons and is certified to be operating withia acceptable paramateis.
TYPE OF ASS�LY
❑ Reduced Pressure Principle o Pressure Vacuum Breaker
�c Double Check Valve o Amoosphere Vacuum Bnaler
Maaufacturcr i` �'- G O Size
z� .
Model Ivumber l� �d Located At I �`Or1�t' l:C� �
Serial N�ber � a7.�'��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACi�LTM BREAI�R
Doubie Check Valve Assembly
lst Check I � 2nd Checi: �3 Relief Valve �►ir Inlet Checic Valve
Initial Test DC-Closed Closed Ti;ht � Opeaed at Opeaed at _osid
Ti�i � Leal:ed � gsid _�nsid
�af7� RP-_�sid
�+� � Did not Open o I,cal;ed o
RePai�
and
Materials
Used
Test ARer DC•Closed Closed Tight o Opened at Opeaad at _nsid
Repair Tight o _nsid __osid
RP sid
Tbe above is ceRified to be true.
Firm Name� 2( y� L� Catified Testa �U � � ��'
,
Firm Addrts,s � �� ✓ Cert TGster No. ' ��Date �
Gauge # �`j�j�� Cj
llate last accuracy tested � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy