2011_0627 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTIOjN ASS L TEST � NANCE REPORT
NAA� OF PWS: � �, PI,I _ I F � �'�rl /j%
PWS I.D. # G, /
LOCATION OF SERVICE: � ✓ ( � r _ [,� -t'� -/
The bacicflow prevention asscmbIy detailed below has been tested and maintained as required by TNRCC
regulations and is ca-afied to be operating within acceptable parametzrs.
TYPE OF ASSEMBLY
Reduced Pressure Principle D Pressure Vacuum Breaker
� D/ouble CLheLck Valve � At/m`osphere Vacuum Breaker
Manufacturer WQ�'77 -T� /� Size/ \�
Model Number � ,/, / � 3 l y� � � Located At W � � C Z� � G
Serial Number o2 57 � � 0
The above ' certified to bre true. ��
Firm N 1 J —� l - Certified Tester - � ' � J
Firm Address 3 � )�Cert Tester No� ��' '` ��- Date / �
Gauge # ���F� %f
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEi�LBLY
PRESSURE VACWM BRFastF'R
Double Check Valve Assembly
1st Check
2nd Cher:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight o
Opined t
�
Opined at
nsid
�r.!„�
Tilt. ,. -. n
RP- , %r, ' nsid
Lcalcd �
Z: psid
nsid
(%C/
Leaked c
Did not Opm o
Leaked o
�Pa�
and
Materials
Used
lest After
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP std
The above ' certified to bre true. ��
Firm N 1 J —� l - Certified Tester - � ' � J
Firm Address 3 � )�Cert Tester No� ��' '` ��- Date / �
Gauge # ���F� %f
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy