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2011_0627 (2)CIIECK ONE: IRRIGATION DOMESTIC FIRELINE BACi�Z,OW PREVENT1OON A$S�LY TEST AND NANCE REPORT NAME OF PWS: � re� I��{Q i' i SC �D� PWS I_D. # _ LOCATION OF SERVICE: The bacicflow prevention 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 Reduces Pressure Principle � Pressure Va�n� Breaker ' � Double Check Valve o Atmosphere Vacuum Breaker Manufacn.ser /��C1�S Size 3 Model Number - f f l l �l Located At � � � r 1 e ZZ �. �C-c- Serial Number � z� The above is certified to be true. _ �� �' Firm Nazae Certified Tester � n � � ff Q Film Address �r Ce:t Tester No. �r� ('� Date Z7 /� Gauge # l'�� Date Iast accuracy tested � �© �© White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSE2�IBLY PRESSURE VACUUM $BEAKER Double Check V aloe Assetably 1st Check tad Chec3: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight D Opined at Opined at osid Tilt , � Leaked o paid osid ��� RP- osid Lcal�cd G' Did not Opm D Leaked o Repairs and Materials Used Test After DC- Closed Closed Tight [7 Opined at Opined at osid Repair Tight O osid osid RP aid The above is certified to be true. _ �� �' Firm Nazae Certified Tester � n � � ff Q Film Address �r Ce:t Tester No. �r� ('� Date Z7 /� Gauge # l'�� Date Iast accuracy tested � �© �© White - Customer's Copy Yellow -City Copy Pink - Tester's Copy