2011_1219CIIECK ONE:
IRRIGATION IllOM ESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY 'TEST AjND MAI2V'TENANCE REPORT
NAME OF PWS: � ���Y° ,�' �" � '^1 O� I
PWS I.D. #
LOCATION OF SERVICE.
Tile bac3dlow prevention assembly detailed below has been tested and maintaiaecd as required by TNRCC
regulations and is ceztified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Princio_ le � Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
\ �o
Manufacturer `-- /LQt� -- Size
Model Number � 1 �� // Located At `-mil "S� i ' 1 ;-
Serial Number `� z-' � U k
The above is certified to be++true.
Firm Name � �� -e i 1 �� ts• Q�
Firm Address � � � }� �� n� 1 fir`- -�
Gauge # 7�>1���
llate last accuracy tested -�l r� I , 1
Certified Teste 1�-/ '� tJ ! � � 1 ` �1
Cent Tester No. ������ Date � I � � I
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF.af`�R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
InivaI Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tight �
Leaked o
� psid
osid
RP- nsld
Leaked c
Did not Open o
Leaked D
�P�
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tigtlt o
Dsid
osid
RP sid
The above is certified to be++true.
Firm Name � �� -e i 1 �� ts• Q�
Firm Address � � � }� �� n� 1 fir`- -�
Gauge # 7�>1���
llate last accuracy tested -�l r� I , 1
Certified Teste 1�-/ '� tJ ! � � 1 ` �1
Cent Tester No. ������ Date � I � � I
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy