2011_0623CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
lliil►���
LOCATION OF SERVICE:
The baclilow prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
O Reduced Pressure Principle ❑ Pressure Vacuttm Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufactzser Size
Model Number Located At
Serial Number
The above is certified to be true.
Film Name
Firm Address
Gauge #
Date last accuracy tested
certified rester - ,,...:
Cent_ Tester No. Date < - -,,�_
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight ❑
Opined at
Opined at
nsid
Tight o
Leaked ❑
psid
nsid
RP- nsid
Leaked ❑
Did not Opm ❑
Leaked o
�Fa�
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opined at
n_ std
Repair
Tight �
nsid
nsid
RP std
The above is certified to be true.
Film Name
Firm Address
Gauge #
Date last accuracy tested
certified rester - ,,...:
Cent_ Tester No. Date < - -,,�_
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy