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2014-0908 (2) h C�IECK ONEs IRRIGATION DOMESTIC � FIRELINE BACTC�Z,OW PREVENTION ASSFN�LY TEST AND MAIN'I'ENANCE REppR? NAME OF PWS: V I G�` � i" ' e� PWS I.D.# ,,t � ,�} LOCATION OF SERVICE: ��'C� 'v • ��Uf'1 �QIQ 1'�,,,�, The bacl�low preventioa asscmbly detailed below has bezn tested aad maint�in� � nqu� �, �CC regulauons aad is cettified to bc operating withia acceptable paramcters. TYPE OF ASSEMBL� ❑ Reduced Pressure Principle � Pressure Vacu�Breaker 1$ Double Chcck Valve o Atmosphere Vacuum Breaker Maaufact�uer �.�.JC��t'� Size �r� Modellvumber �� 1 �� LocatedAt iy Or�� 5��e d� SCY'�c�� Serial N�ber �Z-jI CD� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R Doubie Check Valve Assembly lst C3eck � •1 2nd Checl: � �`� �ef Valve �1ir Inlet Checic Valve Iniaal Test DGClosed losod Tight Opeaed at Opeaed at _esid Tisht Lcal:cd o psid __�osid �Q�j� RP-_psid �� Did not Opcn o Leaked o �P� and Materials � Used Test After DC-Closed Closed Tight o Opeaed at Opeaed at _nsid Repair Tight o _�Dsid __�osid RP sid Tlie above is certifiod to be true. Firm Name �� Catified Tcsta � I � '�Q� 7� � � Fi:m Address � � Cest Tester Na � Date �� Gauge � _ �.SS Q�� llate last accuracy tested � White- Customer's Copy Yellow =�ity�Copy Pink-Tester's Copy