2011_0627CHECK ONE:
IRRIGATION
DOMESTIC
FIRELIN
BACKFI.OW PREVENTION ASSEN�LY TEST AND MAINTENANCE REPORT
NAME OF PWS_ <
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assanbly detailed below has been tested and maintaiaed as rzquired by TNRCG
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
g Reduced Pressure Principle D Pressure Va�-+n•**4 Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �Q� Size � ". r
Model Number �(��� �� Located At '
Serial Number �`�I � -S �--'
The above is certified to be true.
Firm Name ' ' _� �. Certified Tester
Firm Address f 3d3 1� � ` ✓ Ccrt Testa No. � ' Dau .
Gauge # � 8�✓
Date last accuracy tested � .2-� %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJi.TM BRFAitF'R
Double Cher3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Chec3c Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Tilt a
Leaked o
psid
o_ sid
RP- nsid
Leaked �
Did not Open o
Leaked �
�Fa�
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ' ' _� �. Certified Tester
Firm Address f 3d3 1� � ` ✓ Ccrt Testa No. � ' Dau .
Gauge # � 8�✓
Date last accuracy tested � .2-� %�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy