2011_1216 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OFA �COPIP-E�LfL I �L 1
PWS I.D.# I�l t,ke-- 4 T-w �F S�Pi
s n
LOCATION OF SERVICE: '7 d O I v n� - �P n n �O • I 4 P K-.l-
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer Ja- 4-S
Model Number _762
Serial Number T A - 1 ( -
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
O Atmosphere Vacuum Breaker
Size a
� �+ /
Located At �/ 6 u / 1 ` 64C- OL Eorq n c `e-
The above is certified to be true.
1& -4 ,&* 0.-1
Firm Name <! �� Certified Testa
Firm Address 41-1, &1,pt d Tic76'2416at. Testa No. 9,0 -?,5 Due - /-;?
Gauge # n4P11pe-109
Date last accuracy tested ? 8 - i/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
it Inlet
Check Valve
Initial Test
Qa 91�2
DC-Closed
Tisht3
RP -_psid
Leaked ❑
Closed Tight
Leaky 0
3,0
Opened at
osid
Opened at
nsid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight t7
Opened at
osid
Opened at
osid
_____-_p sid
RP sid
jl
The above is certified to be true.
1& -4 ,&* 0.-1
Firm Name <! �� Certified Testa
Firm Address 41-1, &1,pt d Tic76'2416at. Testa No. 9,0 -?,5 Due - /-;?
Gauge # n4P11pe-109
Date last accuracy tested ? 8 - i/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy