2010_1111 (2)CHECK ONE_
IRRIGATION
DOMESTIC
FIRELIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � t`l tlsa � � ( �. � ��C � v
PWS LD. #
LOCATION OF SERVICE:
wog
The bacicflow prevention assembly detailed below has bem tested and maintained as required by TNRCC
rcgulaaons and is certified to be operating within acceptable parameters_
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer �ep�
Model Number os�
Serial Nimmber N E��' � � 2
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located AL
r!l-
The above is certified to be true.
.�-
Firm Name Q �' -�— S Certified Tester � � � � _
Firm Address � � � � �, Y Cert_ Tester No. �P����sg Dau / / �
Gauge # l,- `ac���
Date last accuracy tested 1p �� � i7
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Check Valve Assembly
1st Chet:
Znd Chekl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight d
Opened at
Opened at
osid
Tilt �
Leaked ❑
psid
osid
RP- osid
Leaked ❑
Did not Opm ❑
Leaked o
Repairs
and
Materials
Used
Test AR.er
DC- Closed
Closed Tight ❑
Opened at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
.�-
Firm Name Q �' -�— S Certified Tester � � � � _
Firm Address � � � � �, Y Cert_ Tester No. �P����sg Dau / / �
Gauge # l,- `ac���
Date last accuracy tested 1p �� � i7
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy