2010_1008CIIECK ONE=
IRRIGATION
DOMESTIC
FIRELIN E
BACKFI.OW PREVENTION ASSEA�LY TEST AND I�LA.INTENANCE REPORT
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NAME OF PWS: ___ _
PWS I_D_ #
LOCATION OF SERVICE: � f- +- '�
The bacicflow prnvmtion asscmbiy dctaiicd below has been tested and maintained as required b�- TNRCC
rcgttiations aad is certifed to be operating within acce-ltabie parameters.
TYPE OF ASSEIvfBLY
❑ Reduc�i Pressure Princiu_ Ie ❑ Pressure Vann***, Breaker
�: Double Check Valve ❑ Atmosphere Vacuum Breaker
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Manufacturer � j Size
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Modei Number 1 _� � Located At / �%' -�'t ���-e
Serial Number t` 1 �j
The above is certified to be true.
Firm Name ` = � >i.. '� . Certified Tester '-� � �%
Firm Address C7=.' �t'cyii" i--�i �� �--• Cat Tester No. ;-�i Wi=t 7S�j Date t ` icy i i O
Gauge # .:Si3 �^�'
Date last accuracy tested � Zcj � l.?
Waite — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE aSSE1�iBLY
PRESSURE VACUUM BRF a�'FR
Double Chec3c Valve Assembles
1st Chec3:
2nd ChecS:
Relief Valve
air Inlet
Check Valve
Initial Tcst
DC- Closed
Closed Tight O
Opined at
Opened at
osid
Ti_sht n
Leaked ❑
psid
osid
RP- osid
Leaked O
Did not Open o
Leaked n
Rep arts
and
Materials
Used
Test Aftrs
DC- Closed
Closed Tight �
Opened at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name ` = � >i.. '� . Certified Tester '-� � �%
Firm Address C7=.' �t'cyii" i--�i �� �--• Cat Tester No. ;-�i Wi=t 7S�j Date t ` icy i i O
Gauge # .:Si3 �^�'
Date last accuracy tested � Zcj � l.?
Waite — Customer's Copy Yellow —City Copy Pink — Tester's Copy