2013-1119 C�IECK ONE:
IRRIGATION�_ DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSEMBLY TEST AND MAIIV I'ENANCE ItEppRT
NAMEOFPWS: C �rY BF �'oPP��L
PWS I.D. #
LOCATION OF SERVICE: ��.S I� • n G +.�r6►.� l+� �D. �S O�9
The baci��flow preveation assembly detailed below has ban tested and maintained as nq� �, '�CC
re�lauons and is cerdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Press�ae Principle ❑ Pr�ssure Vacu�Breaker
G� Double Chxk Valvc o Atmosphcre Vacuum Brealer
Manufacturer �r�SC6 S� � `�
Model Iv�ber ��� Located At I��o►�`►" �K-u>y AT �I E T FiQ..
Scrial Ni�ber � C 3`l I`��l
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check 2nd Checl: Reiief Valv� Air Inlet Check Valve
Inival Test DGClosed Closed Ti;ht Opened at Opeaed at nsid
Ti�tt Leal:ed ❑ �sid __osid
R.P-2� l psid � , Z
�� � Did not Opea o L,eaked ❑
�P� -
and
Materials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at nsid
Repair Tight o _�nsid nsid —�
RP sid
The above is cerafied to be�rue.
Firm Name ��-� �c r,✓e d�►�k Gc,o� Catified Tester �+r-�i s ro Gr�-E� ��t�Fa-2 m
Firm Address l�l 1� L r►�.�v D� �`�I 63 Cert. Tester No. ��o-013 3610 Date 8 -13-1'�
G:9E�.Dl.lTa,v , Tx 7SOo7
Gauge # D$o ynsS3 L;��
llate last accuracy tested � )- 19-I 3
White - Customer's Copy Yellow - City Copy Pink- Tester's Copy