2011_1219CHECK ONE:
IRRIGATION DOMESTIC FIR E LIN E
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
i t 11
NAME OF PWS: � _n�O�i! i � �Gl l � SG��v : ��-
PWS I.D. #
LOCATION OF SERVICE: � �� � W'(�Y`� IE' -�✓� �� �'
The baci. -IIow prevention assembly detailed below has been tested and maintained as required by TNRCC
reguiations and is ca�tif � to be operating within acccptablc paramctrrs_
TYPE OF ASSEIv1BLY
� Reduced Pressure Principle o Pressure Vacuttm Breaker
� /D��oublettC�heck Valve o Atmosphere Vacuum Breaker
Manufacturer l/LJQi'i S Sizc � �Z
Model Number �� -/ � Z � Located At =� eei r r q O � ft ��u
Serial Number �I3 �� Z r
The about is ce:'tificd to be true.
Firm Name P s i -�s�- Certified Tester n U� 1 e
Firm Address � �� �� Y� Ccrt Tester No. BPG��� Date ��' � ��
Gauge # �_. --�� j �7
Date Iast accuracy tested `� � 3 � %
Whfte — Customer's copy YeIIow -city copy Pink - Tester's copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTiJM BRFASC'F•R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight O
Opened at
Opmcd at
osid
Q
Tilt �
R.P- osid
Lcakcd o
3.f psid
osid
Leaked o
Did not Opm o
Leaked o
�P�
and
Materials
Used
Teri Ai3er
DC- Closed
Closed Tight o
Opined at
Opined at
n_ sid
Repair
Tight �
nsid
osid
RP sid
The about is ce:'tificd to be true.
Firm Name P s i -�s�- Certified Tester n U� 1 e
Firm Address � �� �� Y� Ccrt Tester No. BPG��� Date ��' � ��
Gauge # �_. --�� j �7
Date Iast accuracy tested `� � 3 � %
Whfte — Customer's copy YeIIow -city copy Pink - Tester's copy