2014-0908 (4) C�IBCK ONE:
IRRIGATION DOMESTIC -� FIRELINE
BACT4'LOW PREVENTION ASSEN�LY TEST AND MAINTENANCE REppRT
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NAME OF PWS: �J
PWS I.D.#
LOCA?TON OF SERVICE: �� � - �1"C�C�Y1 (G�e'� ,
T'he bacl�low preveatioa asscmbly detailed below has been testod and main ain� � nq�� �, �gCC
rcgulanons aad is catified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuimi Breaker
,� Double Chcck Valve o Atmosphere Vacuum Brea�er
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Maaufactiaer ��TS Size
Model lv umber �� � ' C�T I Located At `�
Serial N�ber ( �� [ ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE YACUUM BREAKER
Double Check Valve Asaembly
lst Check �.q 2ad Ch�cl: (,�'j �ef Valve A►ir Inlet Check Valve
Inival Test DC-Closed Clos�d Ti�t � Opeaed at Opeaed at _esid
Ti�t � Leal:ed 0 nsid __�osid
RP-_psid
Leal►ed � Did aot Open 0 Leal;ed ❑
�P�
aad
Materials
Used
Test After DGClosed Closed Tight o Opened at Opeaed at _osid
Repair Tight ❑ _^�sid nsid
RP sid
Tho above is catified to be true.
Firm Name�� e -�--5� Catified Testa �C� ►�
Fiim Address � '� a V Cert. Teste No.��.1�-�0�� Date �� I`-t
Gauge # �'��j(��
llate last accuracy tested ��
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy