2014-0908 (5) C�IBCK ONE:
IR$IGATION � DOMESTIC FIRELINE
BACKFI,OW PREVENTION ASSENiBLY TEST AND MAINI'ENANCE REppRT
NAME OF PWS: A�tm l ti'115�rc�T�� U Y1 �J�C��
PWS I.D. #
LOCATION OF SERVICE: �� S' ' �C�'1�C�1'1 Q�
Tbe bacl�low preveation asscmbly detailed below has been testod and maint ;r� � nq� �, 'i'�CC
regulanons aad is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
¢�- Double Chxk Valva o Amiosphere Vacuum Breaker
���
Maaufact�aer �e�dG Size
Model Number g�0 Located At • �a�
Scrial Nimnber �� ���l,P
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check Z�S 2�d Checi: 1 �°� �ef Valv� A►ir Inlet Check Valve
Initial Test DC•Closed Closed Ti;ht � Opeaed at Opened at _esid
� Ti�t � Leal:ed o _,nsid _,_osid
PQ RP-__psid
�a o �a not oP� o r�;�a o
�� ,
�a
Ma��
u�a
Test After DC-Closed Closed Ti,pht ❑ Opened at Opmed at _�sid
Repair Tight o __,,,�Dsid __osid
RP sid
The above is ccrtifiod to be tive.
Firm Name � `�S� Cerdfied Ta�ter �GU �� � �
Firm Addr+ess ��J �"-'f�� �✓ Cat Tes�ter No.1J��b���Date � � l
� � �
Gauge # ���
llate last accuracy tested`-�f` �j ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy