2010_1111 (2)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEA�LY TEST AND MPiINT'ENANCE REPORT
NAME OF FWS: � r�P.I l � ', �'y �!- _.F_. � `.. ;,.� -'��1<
PWS I_D. #
LOCATION OF SERVICE: � �' � � `,
The bacl�low prevention assctnbly detailed below has been trsted and maintained as required by TNRCC
regulatiorts and is certified to be operating within acceptable parametcss.
Manufacturer
Reduc. -d Pressure Principle
Double Check Valve
��-�_ � _,
Model Number !1d� � � � -�'
Serial Number '�? _ �� � `��
TYPE OF ASSEMBLY
� Presstaac Vacut�. Breaker
Atmosphere Vacuum Breaker
�.!
Size 7
Located AL W � '? �� C°
The above is certified to be true.
l
Firm Name � -Ci (� �� � --t—c � 1J Certified Tester V • f 1Q � E'+- -1
Firm Address ! 3e�� e;J rcd/19 �f' ✓(� r� Cart_ Tester No. B�o�Y0�58 Date �� l ► %! D
Gauge # � '?� t'.�_ i[7
Date last accuracy tested �^ � � � � 1 Ca
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSL`RE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Chec3t Valve
Initial Test
DC- Closed
Clos«1 Tight �
Opened at
Opened at
osid
Ti�at O
Leaked O
psid
osid
RP- osid
Leaked �
Did not Open �
Leaked D
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight 0
psid
osid
RP sid
The above is certified to be true.
l
Firm Name � -Ci (� �� � --t—c � 1J Certified Tester V • f 1Q � E'+- -1
Firm Address ! 3e�� e;J rcd/19 �f' ✓(� r� Cart_ Tester No. B�o�Y0�58 Date �� l ► %! D
Gauge # � '?� t'.�_ i[7
Date last accuracy tested �^ � � � � 1 Ca
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy