2011_0902CHECK ONE:
IRRIGATION FIRELINB
DACKnOW PitEVENTION ASSLMNLY TEST AND MAUMNANCE REPORT
NAME OF PWS:
PWS IM it /�
LOCATION OF SERVICE- I� ! V o/- M- /got yi (�
The bacldlow pmv ®on assembh. detailed below has been WOW and ma ataine+d as required by TNRCC
regulations and is catifiW to be operating wuh= &=pusbic parametrss.
C Refted Pressure Pn=Pie
❑ Double Check Valve
Manu.acwrer H
Model Number P L
Serial N=ba I S -L q__r_�__
TYPE OF ASSEMBLY
a Pressta+c V=A= Bteaica
C Atmospbat Vacu— Breaiw
Size
Located At
The above is cardfied to be true.
Firm Name A L—� , ''``�' i f� CersBad Tetra G ,,. -e ,> .�...._..._... S_
0 '1 �l Cent Toga No.
4, t,, C- L -.. t
Gauge i q 3T t3,
Date last accuracy tested 1 '
White - Customer's Copy
kt
Yellow - City Copy
Pink - Testery Copy
REDUCED PT L m PRLNCIPLE ASSEA�LY
PRESSURE VACUUM BREAKER
Double Cheek Valve Ass mbly
1st Check Sod Check Relief Valve
Air INet
Check Valve
Imnal Test
DC- Closed
Closed Tight
Opawd at
Opamd at
Tilt ( , (p #,
Lcaked
"Sid
_.� id
�Un
R?. ---mid
Lulled p
Did wt Open C
Lcakod O
Reps
!
and
Maesnals
Used 1
Test ARa
DC- Closed
Closed Tight o
Opened at
Opened at
_
Repair
Tight o
-- —jpsid
---. ---pad
RP id
The above is cardfied to be true.
Firm Name A L—� , ''``�' i f� CersBad Tetra G ,,. -e ,> .�...._..._... S_
0 '1 �l Cent Toga No.
4, t,, C- L -.. t
Gauge i q 3T t3,
Date last accuracy tested 1 '
White - Customer's Copy
kt
Yellow - City Copy
Pink - Testery Copy