2010_1008 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND M.AiN'I'ENANCE REPORT
NAME OF PWS.
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 paramesrss-
TYPE OF ASSEMBLY
o Reduced Pressure Principle o Pressure Va�uL Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Modci Number
Serial Number
Located At
The above is certified to be true.
Firm Name . �" L �:=` Cr' � i �q� -�-, .�s� . _Q� - � _ f Certified Tester
Firm Address � �J����r�+�u(�,j�Yt -+`s' Cent Tester No. Date
Gauge # � ' j�Q
Date last accuracy tested � Z� r U
White - Customer *s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRE_A►T�'R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight o
Opmcd at
Opined at
nsid
Tight o
Leaked C7
psid
nsid
��S
RP- nsid
Leaked �
Did not Opm o
Leaked D
�P�
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opmcd at
Opined aL
nsid
Rapair
Tight o
nsid
nsid
RP std
The above is certified to be true.
Firm Name . �" L �:=` Cr' � i �q� -�-, .�s� . _Q� - � _ f Certified Tester
Firm Address � �J����r�+�u(�,j�Yt -+`s' Cent Tester No. Date
Gauge # � ' j�Q
Date last accuracy tested � Z� r U
White - Customer *s Copy Yellow -City Copy Pink - Tester's Copy