2010_1110CIIECK ONE:
IRRIGATION DOlYI ESTIC FIR E LIN E
BACKFI.OW PREVENTION ASSEA�LY 'PEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The bacl.-IIow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cQtifaed to be operating within acceptable parameters_
TYPE OF ASSE2vIBLY
Q Ruiuced Pressure Principle � Pressure Vacutzm Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Scria! Number
Located At
The above is certified to be true.
Firm Name 'L- U • � � �-° f I (��� - S � • Cettfied Tester
Firm Address � � ' -' � "" f a�� � Cent Tester No Date '��
Gauge # �5����
Date last accuracy tested � Z9 � b
White - Customer's Copy Yellow -City Copy PirUc - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACIT[JM BEZFAK'>~'R
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight D
Opined at
Opined at
nsid
Tishi �
Leaked o
psid
nsid
RP- nsid
Leaked c
Did not Opm o
Leaked D
�P�
and
Materials
Used
Test After
DC- Closed
Closed Tiehi O
Opined at
Opined at
nsid
Repair
Tighe o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 'L- U • � � �-° f I (��� - S � • Cettfied Tester
Firm Address � � ' -' � "" f a�� � Cent Tester No Date '��
Gauge # �5����
Date last accuracy tested � Z9 � b
White - Customer's Copy Yellow -City Copy PirUc - Tester's Copy