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2016_1010 (2) . � � 5�� r � ~ . . ,�f, r...� , �� . , �� IRRIGATION� � ` �f)OMES7I�C � � FIRELINE � `� �� `"� , , : � � �, ..� � � � � The �following form mu�t��be cbr�pl�t.�d for each asse�bly��tested.��A signed and�dated original � � � must be submitted to the p�blic'vYate�'�p�lier for recordkeeping�urpases: , �,� � �� '�L - � ��- � �� BACKFLOW P�ZE�E�'T�E31�T AS5EM�LY TEST Al�'D MAINTENANCE REPORT NA1�i1E OF PWS: CIT�.Q� C.��:��LL' PWS-I:D. #U570U4Q (Cus'tomer) , M.4ILING ADD S. ,��°�' � -' ,�.. � r� �' {"r ��, f �',.,� �, ;�J �`�-� �r CONTACT PERSON/P P " ' � :: � LO��TION OF SERVICfi:., � ,_;. , -, �. � ��'3�. '�..,1.'�( ;`v' E:' ; , � '; � The�iackflow prevention ass�t��ai1�d beiow has been tested a,nd maint�ined as req_' d by : commission regulations and is c��e�to be operating within aceeptable parameters. 'TYPE OF ASS�iVIBLY -� ❑Reduced Pressure P�nc�iple ." ❑Reduced Pressure Principle-Detector ❑Double Check Vaiv�, `` . ❑Double Check-Detector � � � ❑PressureVacuuniBr+��er` `�� ❑Spill-Resistant�Pressure Vac umBreaker � � � � ; r � � t Manu�'acturer��`� �` '� 1L'Io�e1 Nuinber �,.- � �� Size , � � �, 51'' o � .� �, ; F ` Locat�d At � ��' ��y �``.; "�� '�'^�� . Serial Nuxnber � f � � .� � � .. ,,., ; Is the�ssembly installed in accQrd�rice��ith rna�ufa�turer recommendations and/or local eodes?� � �;r.� `ft�sx _ "�� . . , , r��,� y�� '�,� , r� ��,� + R� �ed�re�s� �'Arinci le Assemb Pressuxe V �uum �aker ��;��,, . � ° DoubleCheek�af�e'ASsett�bly, � � � � � � � � � � � • �eliefValve � � AirI et� � Ckeck Valve v' 1 st Checl� , , 2nti��eck ; ; ; „ , . - - - � . � �� . _ .:.,. .� �. , ` � - - `'�� He1d at � , pat� I�e�tt� ��," psid Opened at � � Op"�� ed a .�� Field at � Initi�l Test Closed Ti htC3 ��d Ti ht ❑ psid d sid g � . g P P Leaked� �,eaked'��J;` idnotopen ❑ Did Leaked❑ Repa�rs/ : '``, . '� �ts� ''^'� � � � Matet`ials �' � �� ,: �_�,� : : Used � �, � �"�`�' � v � '� �..r Held at � '� p5�d ��eld�t��psid Test�►fter � : , Opened at Opened at � Held at Repa�r Closed Tig�t`�ly 'C�a��r�'I'ight� psid psid psid ��, . Test�auge used:Make/Mcc�d�l ^ ' �""-`"�"'� � SN: �; �,� �.� �� Date,�'ested for Accuracy: ;� �' `'�.�- ' � RemaGrks: �� The.��ove is�certifted to b�true�.�it��-�t��e of testing. � � � � � � � � � � � � � � ' �. ;. , , . . , : �. :�,, �. Firm Name� �"`��"`� Firm Address � :� � � �""� ��. �, �'� ' �� '� � ` ., ` , �� ,� ��^+ �,,,.�., � �. ...�, , Certiflad Tester(print)�� -`� '��" Certified Tester(signature)�� "� - , � �� -, �, � ^� , Firm phone# �� / ' .�>� � ��'�� Cert.Tester No.�� Date '�'�.�' ` � �� ' � �� , *TEST RECORDS MUST BE�pT.�'dR AT LEAST THREE YEARS : **USE ONLY MANUFA�'�'L7R��'5 REPL��EMENT PARTS ` White`-City Copy '�"ellow-Custonner�Copy Pink-Tester's Copy w k t .. .� y . .r ':l� ., �. � .. . . ._�. .. .. . . .. '.. `�':.�� . .,.:." �... _u Aw�.::. ....." �:: . 1.. .,.;..� , �� ..::: ' .... , M . . a':�h. ..,...1.� eW a..�.:4 .��..w✓ .....,... . . , �_.. _ �.