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2011_1219 (4)C� CIIECK ONE. IRRIGATION DOMESTIC FIRELIN BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTEI�IANCE REPORT � ) NAIvfE OF PWS: � � D e I ( � C� 1 � -� Cj O PWS LD. # r LOCATION OF SERVICE: � � Lx * ��yJ �-� � `V The bacl.-tlow prevention asscznbhr detailed below has been tested and maintained as required by TNRCC rcgusanons and is certified to be operating within acceptable parameters. TYPE OF ASSEIvfBLY C� Rcduc:.d Pressure PrincinIe o Pressure Va�-u� Breaker 7 Double Check Valve o Atmosphere Vacuum Breaker Manufacitarer : �u :- Size Model Number �Q ©�� L.ocatcd At Scrim I�iumbcr �' 1 � `-� � � -- -� The above is certified _to be true. � � ��.% Firm Name �fJe__, �.! � -�-- r`J' Cettifiea Tester .C.(u � C./ a�l ' e Firm Address �? 0 Y Cent Tester No. �� Date � q �r""`� Gauge # �� a ice'•``) llate Iast accuracy tested / �� White — Customer's Copy Yellow —City Copy Pink — Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEriiBLY' PRESSURE VACiTC7M BRF.at,'FR Double Check Valve Assembly Ist Cher1: tad Chekl: Relief Valve Air Inlet Check Valve Ininal Tcst DC- Closed Closed Tight o Opened at Opined at nsid Tilt o Leaked � � � psid nsid RP- nsid Leaked C Did not Open o Leaked Q Rcgaus and Materials Used Test After DC- Closers Closed Tight D Opined at Opined at nsid Repair Tight Q nsid nsid RP lid The above is certified _to be true. � � ��.% Firm Name �fJe__, �.! � -�-- r`J' Cettifiea Tester .C.(u � C./ a�l ' e Firm Address �? 0 Y Cent Tester No. �� Date � q �r""`� Gauge # �� a ice'•``) llate Iast accuracy tested / �� White — Customer's Copy Yellow —City Copy Pink — Tester's Copy