2011_1219 (2)CHECK ONE.
IRRIGATION DOlYiESTIC FIRELINE
�' BACKFLOW PREVENTTION ASSEj MBLY TEST AN+D MAINTENANCE REPORT
NAME OF PWS: n '7�Jy_ 1 e `` :�,►` ���OC�!
PWS I_D. # c� f � (�
LOCATION OF SERVICE: P X � \.'` `' O►" f� -VJQ� �' J 4 SIC'
The bacicflow prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certit-cd to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C� Reduced Pressure Principle o Pressure Vacutmm Breaker
u Double Check Valve � Atmosphere Vacuum Breaker
I
Manufacturer � �1 1'7 S Size Z �Z
Model Number � 7 Located At � . �-+�' ' `�� ,, � °�--Z�
Serial Number � �� D � � i l
The above is certified to be tzuc.
Firm Name � ��� � -- •S• � • Certified T'cste ' •; � ,
-� f�,'f
Firm Address � d� e_.�- a�l,� -�✓ Cent Tester No. 5 Dau � �� �(
Gauge # ���`1�`Y
Date last accuracy tested � (�j � /
White - Customer °s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRIPlCIPLE ASSE1�iBLY"
PRESSURE V 3CLTUM BRF,tK'�'R
Double Check Valve Assembly
1st Cher:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Ininal Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight c
Leaked o
psid
osid
RP- osid
Leaked c
Did not Open o
Leaked Q
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight [7
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be tzuc.
Firm Name � ��� � -- •S• � • Certified T'cste ' •; � ,
-� f�,'f
Firm Address � d� e_.�- a�l,� -�✓ Cent Tester No. 5 Dau � �� �(
Gauge # ���`1�`Y
Date last accuracy tested � (�j � /
White - Customer °s Copy Yellow -City Copy Pink - Tester's Copy