2014-0908 s
C�IBCK ONE:
IR$IGATION � DOMESTIC FIREL
INE
BACI�'I�OW PREVENTION ASSEIV�LY TEST AND MAINTENANC'E REppRT
NAME OF PWS: t �
PWS I.D. #
LOCATION OF SERVICE: S SD I� . 1 �PI'l�r�r'1 i n. � . �Q
Tbe bacl�low preveation asscmbly detailed below has beea tested aad maintaiaed as required bv 'I'NRCC
re¢uladons and is cen�i5ed to bc operating withia acceptable paramcters.
TYPE OF ASSENIDLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaker
� Double Chxk Valve ❑ Atmosphere Vacuum Bnaker
Maaufacturer � �� I�1 Yl I ��Z
�_ Size
Model Number � S���-�- 1 Located At N� S� o`e. o� S�-�t�)
s«;�N��� 5� i(�3�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check Z,3 Znd Checl: Z�� Relief Valve 4ir Inlet Check Vaive
Inidal Test DC-Closed Closed Ti�t Opeaed at Opraed at _nsid
Ti�i Leal:ed a osid __�osid
��j� RP-_,psid
�►� � Did not Opcn o Leaked ❑
�P�
aad
Mataials
Used
Test AR,er DC-Closed Closod Tight o Opeaed at Opcned at _nsid
Repair Tight ❑ _��sid __nsid
RP sid
The above is certifiod to be true.
Firm Name�n ��� . Cerdfied Tes�ex ! )►
.
Fitm Addrtss_�3 wCGF t��' Cat Tester No. � � Date I � l`1
cauge # ��j(..�
llate last accuracy tested '� �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy