2010_1111CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACICI�ZOW PREVEN'T'ION ASSEMBLY TEST AND M.4I2�1'I•ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow ptovmtion assembly detailed below has been tested and maintaiaed as tzquired by TNRCC
reguiations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle o Pressure Vactnmm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true, p r
Firm Name �.--t� � � -�- S � • Cetrified Tester � • rJQ ! 1
Firm Address J 3 � � tL? /'r a�✓ Cert Tester No. � �� ����ate / / / � /U
Gauge # �� �DOC�
Date last accuracy tested �+ z- ) L�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM SRFAT�R
Double Cheek Valve Assembly
1st Check
Zttd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opmcd at
Opined at
osid
Tilt C7
Leaked o
psid
osid
RP- osid
Leaked o
Did not Open �
Leaked C7
�Pa�
and
Materials
Used
Test AR,er
DC- Closed
Closed Tight o
Opined at
Opened at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true, p r
Firm Name �.--t� � � -�- S � • Cetrified Tester � • rJQ ! 1
Firm Address J 3 � � tL? /'r a�✓ Cert Tester No. � �� ����ate / / / � /U
Gauge # �� �DOC�
Date last accuracy tested �+ z- ) L�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy