MA 9601-LR021125 (2)Dec 23 OE 09:26a
C.,IECK ONE:
IRRIGATION
Dentax / Double Check S40-387-8787 p.2
DOMESTIC FLRELLNE J
BACKFLOW PREVKNTION ASSEMBLY TEST AND MAIN 1 ~Iq',i~CE REPORT
NAME OF PW$:
LOCATION OF SERVICE
Manu.t'acmrer
Model Number
Serial Number
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Azmosphere Vacuum Breaker
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACI.rUM BRF.,AK~R
Double Check Valve ~s~bly
1~ ~e~ 2nd ~e~ R~ef V~e ~r/.I.t ~e~ V~ve
~d~ T~t DC-Clos~ Clos~ Ti~t = ~ at ~ at psid
Ti~ m ~ o psid p~d
~-~sid
~dnot~ ~ f~ ~
Ma~
Us~
T~ ~ DC-CI~ Clos~ Ti~t = ~ at ~ at psid
~ Ti~t ~ psid psid
~ psid
The above is c~t~Sed to be true.
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy