2015_0119 C�IECK �NE:
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IRRIGATION ���"'�!���'� �f�"�',� 3 Z��S
OMESTIC FIftELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C�� � P�I`
PWS I.D. #
LOCATION OF SERVICE: (�-� I �1 V 1� � I � V`�
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The backflow prevention assembly detailed below has been tested an m�a ntaine a q ire y CEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breakcr
-0�� Double Chcck Valve � Atmospherc Vacuum Breal:er
Manufacturer
�h-�S Size �� 1
d
ModelNumber `r' —� � W1 � LocatedAt 1�"� V`^� �r N� � cu�,�
Serial Nimmber 6�' $�' �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAKER
Double Check Valve Assembly
lst Checl: lnd Checl: Reiief Valve :�►►ir Inlet Check.Valve
Initial Test DGClosed osed Ti;ht Opened at Opened at nsid
Ti�t. � Lcal:ed o psid osid
� �4 RP-�psid '� �
Lcal;cd a ' Did not Open o I,eaiccd a
Repairs
and
Maurials
Used
Test Af�s DC-Closed Closed Tight ❑ Opencd at Opcned at nsid
Repair Tight o nsid nsid
RP sid
The above is certified to be 1 �4�
� � (�`�� G-e � i3�---r`�--d��
Firm Name ��S Certified Testa �
�r g ��' al�cit , y
Firm Address�� ,t�-� ���C /�Y� Cat Tester No. ��13!�� Date�"��"5�I�
(�auge # ('� � �
llate last accuracy tested 1� 1�`��
White - Customer's Copy Yellow - City Copy Pink -Tester's Copy