2011_0714CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKPFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. Al
LOCATION OF SERVICE:
The barlilow pmve=on assembh. detailed below has been tested and - maintained as required by TNRCC
rtgulamons and is ccr ihed to be operating with= acceptable parmma=.
C
C�
Reduced Press= Pnnc.plc
Double Check Valve
Manu:aetiaa
� �'�I
Model Number
V VI ( &T-
Serial Number
TYPE OF ASSENSLY
O Pressure Vacuum Breaker
C A ®ospbere Vacuum Breaker
Sin -3 Z �
Located At
The above is certified to be tr ix.
Firm Name C- f �(P,- � i ( r L y f J 1) Certified Testa � � G"`' f, �,�•. 5
Ftrm Address a_ o:& -7q-? Cent Tester No. 6f Ongel 3 Dane
U/mAtIf -CIA -'e T-I\
Gauge g 01 LI ]q 13
Date last accuracy tested
White - Customer's Copy Yellow - City Copy PING - Tester's Copy
REDUCED PRESSURE PMCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
IbNOWNWANOMMONOW mina] Test
DC- Closed �,
Tight
Closed Tight
Leaked
Opened at
sid
Opened az
__.psid
___psid
RP- _,_psid
I ask-ad p
Did not Open O
Leaked C
r pt
nd
Mauruds
Used
Test Afta
Repair
DC- Closed
Tight 0
Closed Tight 0
Opened at
flsid
Opened at
grid
RP id
The above is certified to be tr ix.
Firm Name C- f �(P,- � i ( r L y f J 1) Certified Testa � � G"`' f, �,�•. 5
Ftrm Address a_ o:& -7q-? Cent Tester No. 6f Ongel 3 Dane
U/mAtIf -CIA -'e T-I\
Gauge g 01 LI ]q 13
Date last accuracy tested
White - Customer's Copy Yellow - City Copy PING - Tester's Copy