2010_1111CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION gSSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � f �?�'l � � � � _ ----
PWS I.D. #
LOCATION OF SERVICE. � '' -A � -- �i�i ---�`%
The bacicflow prevention asscrnbly detailed below has been tested and maintained as required by TNRCC
rogulations aad is certified to be operaring within acceptable parameters.
C� Reduced Pressure Principle
n Double Check Valve
Manufacturer 3'� L
TYPE OF ASSEMBLY
n Pressure Vacutrm Breaker
e Atmosphere Vacuum Breaker
Size
Model Number �'�!! � A d Located At
Serial Number d � � blD
y ! �`
✓OG- �L
The above is certified to be true.
Firm Name � � �J� � Certified Testa � �. � �
Firm Address 1 � r%� � � �`�1 i Cat Tests No. y � i�' ���ate �� � / /O
Gauge # �' —''� � (�
17ate last accuracy tested � � -) � �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'aT.'F'R
Double Check Valve Assembly
1st ChecS:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight n
Opened at
Opened at
osid
Tight a
Leaked n
psid
osid
RP- osid
Leaked n
Did not Opcn n
Leaked n
Rep airs
and
Materials
Used
Test Afars
DC- Closed
Closed Tight n
Opened at
Opened at
osid
Repair
Tight �
nsid
osid
RP sad
The above is certified to be true.
Firm Name � � �J� � Certified Testa � �. � �
Firm Address 1 � r%� � � �`�1 i Cat Tests No. y � i�' ���ate �� � / /O
Gauge # �' —''� � (�
17ate last accuracy tested � � -) � �
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy