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IRRIGATION DOMESTIC FIHELINE �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'TENANCE REPORT
NAME OF PWS: �I�.(1 ��C-
PWS I.D. #
LOCATION OF SERVICE: ���S (-,r-r�� t1�v�I�►a� ' �/��I �k. 7�()�1
The backtlow pre��ention assembly detailed below has been tested and maintained as required by TCE�
regulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Rednc�i Pressure Pnncipte � Pressurc�Iacu�Breaker
�► Double Check Valve ❑ Amoosphere Vacuum Breal:er
Manufact�er 1n�k�d1. 5 Size ��y��
Modellv�ber �501 Ll ��c�At ���'�" ,,U, W _ �rnr,r
Serial Nimmber ��$��b
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSL'RE VACUUM BR.EAIL'ER
Double C3eck v alve Assembly
1st Checl: 2nd Checl: Relief Valve :�ir Inlet Check Valve
Ininal Test DGClosed Closed Ti�t � Opeaed at Opeaed at flsid
Ti�t �' Lcal:ed ❑ psid osid
p.�S RP-�psid
�� Lcai;ed o l�� Did not Oprn o Leal:ed o
�� fand
Mataials
Used
Tcst After DC-Closed C1Qsed Tight ❑ Opened at Opcacd at osid
Rtpair Tight ❑ �sid osid
RP sid
The above is cutifiod to be tnu.
Firm Name �(i �tSfi Ccr4i5od Tesur �n1��b�4w� Cid�cA�
Fitm Address y Sy� Gr��� � VyctJ Iry�•. Cat Testallo. ���I�((� Deee �• � S
� �. �6z��t
t�auge # b s+316 rs
llate last accuracy tested ' �V ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy