2011_0629CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEIVIBLY'lEST AND MAI �T'I'ENANCE REPORT
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NAME OF PWS: �'� � ('i/�L%f�
PWS I_D. #
LOCATION OF SERVICE: i :. w �' K l ,�< <.f_ c�,�`
The baci.-tlow prevention asscmbiy detailed below has been tested and maintained as required by TNRCC
regulations and is cct-a£ed to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
C� Reduced Pressure Pr1nCI�le � Pressure Va�-*np*.. BrCakCr
� Double Cheek Valve e Atmosphere Vacuum Breaker
-7
Manufacturer � ��'" Size —"
Model Number ���- Located At "U/� � �^
�.
Serial Number �` ' i' -_
The above is ce:tif cd to be true.
Firm Name � ', `L
Firm Address � W fQ R �'
Gauge # � -� �!`' h <_
Date last accuracy tested �p ZG% ) U
.. _.
1 ��
'�1! �.
White — Customer's Copy Yellow —City Copy PinK — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�"F'R
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Checl:
2nd Check
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Ti�u n
Leaked o
psid
osid
RP- osid
Leaked o
Did not Open o
Leaked o
Rcpaus
and
Materials
Used
Test ARtr
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is ce:tif cd to be true.
Firm Name � ', `L
Firm Address � W fQ R �'
Gauge # � -� �!`' h <_
Date last accuracy tested �p ZG% ) U
.. _.
1 ��
'�1! �.
White — Customer's Copy Yellow —City Copy PinK — Tester's Copy