2014_1008 �
C�IBCK ONE:
IRRIGATION__� DOMESTIC FIRELINE
BAC'I�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REppRT
NAME OF PWS: �r��Ic �1�-A✓
PWS I.D.#
LOCATION OF SERVICE: � '�'x�t�.�l��tA--�
The bacl�low preveation asscmbly detailed below has beea testod aad maintaiaed as required by 1'NRCC
roguladons and is certified to be operating withia acceptable paramcters.
TYPE OF ASS�LY
❑ Reduced Pressure Principle o Pressure Vacu�Breaktr
�' Double Chcck Valve o Amiosphere Vacuum Breaker
Manufacturer �P�J LC� Size �'�
Model Number ��� Located At ��� ` aw►J
Serial Nimiber Z'✓�� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double C1uck Valve Assembly
lst Check �, � 2nd Chec1: Z• Relief Valve �►ir Inlet Check Valve
Initial Test DC-Closed Closed Tight Opeaed at Opeaed at _osid
� Ti�t Lcal:ed o �sid _osid
��� RP-_psid
L e a l;e d ❑ D i d not Opcn o L,e a k e d o
�P�
and
Materials
Used
Test After DC-Closed Closai Tight o Opened at Opeaed at ___nsid
Repair Tight ❑ Dsid osid
RP sid
The above is cenifiod to be true.
Firm Name�� � Cetified Tcsta ` I * l
Fiim Address ✓ Cat Teste No. 1`�'�`�' �Date �d
cauge # Z ('� �
llate last accuracy tested �,r
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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