2011_1219 (3)CHECK ONE.
IRRIGATION
DOMESTIC
FIR E LIN
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � � � � ( � -�� � 4` � 1 f�Q
PWS I.D. # , el /� `
LOCATION OF SERVICE: ! ,� � w ' � QY'���� -t�-c 1.� 1 V
The bacicflow prcvmtion assembly detailed below has been tested and maintained as required by TNRCC
regulations aad is certified to be operating within acceptable parameters.
Manufacturer
Reduced Pressure Principle
Double Check Valve
- _�Q-T�
Model Number ✓O /�'//
Serial Number �� � / /y
TYPE OF ASSEMBLY
n Pressure Vacuum, Breaker
Atmosphere Vacuum Breaker
�/� ,:
Size
Located At � C. ��� �,
The above is certified to be true_
r 0 f�� �
Firm Name �]�! D��_ >_� . _ Certified Tester '�._Q_ _V/ Gi C�-i � L��' -7
g�OQ��'7� � i
Firm Addrzss �� � ' -^�- :�zr�(�,�, Cert Tester No. ate �� �'�
Gauge # z-���
Date last accuracy tested `� �3/��
White - Customer °s Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF�K'F'R
Double Check Valve Assembly
Ist Chec1:
2nd Check
Relief Valve
4ir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Tilt �
Leaked O
psid
nsid
RP- nsid
Leaked o
Did not Opm o
Lcal:cd o
RLp atrs
and
Materials
Used
Test After
DC- Closed
Closed Tis�>ht o
Opmcd at
Opined at
nsid
Repair
Tight 0
nsid
vsid
RP sid
The above is certified to be true_
r 0 f�� �
Firm Name �]�! D��_ >_� . _ Certified Tester '�._Q_ _V/ Gi C�-i � L��' -7
g�OQ��'7� � i
Firm Addrzss �� � ' -^�- :�zr�(�,�, Cert Tester No. ate �� �'�
Gauge # z-���
Date last accuracy tested `� �3/��
White - Customer °s Copy Yellow -City Copy Pink - Tester's Copy