2010_1110CHECK ONE=
IRRIGATION
DOMESTIC
FIR E LIN E
BACKFLOW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
_ -� �% )
NAME OF PWS: - aJ �-. �i'
r
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has been tested and maiataiaed as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
o Reduced Pressure Principle
�
Doublej Check Valve
Manufacturer
?X-i_.
Model Number
� S�
Serial Number
k {
1st Chec1:
TYPE OF ASSEMBLY
o Pressure Vacut� Breaker
Atmosphere Vacuum Breaker
t�
size Z•
Located AL E �cr
The about is certified to be true.
Firm Name � %� • / Certified Tes�t,er , � / Qom%
Firm Address %��� .�'i � --a0%� _ �-1r Cent. Tester No. --"�7� Date i � �- /O
Gauge # ��,'`� ��' �' � -? q
Date Iast accuracy tested � Z / ��
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRIl�lCIPLE ASSEriLBLY
PRESSURE VACLTLTM SRFAI.'FR
Double Check Valve Assembly
1st Chec1:
2nd Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tilt o
Leaked o
psid
osid
RP- psid
Leaked G
Did not Open o
Leaked O
�Pa�
and
Materials
Used
Test Altar
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tighe a
osid
psid
RP std
The about is certified to be true.
Firm Name � %� • / Certified Tes�t,er , � / Qom%
Firm Address %��� .�'i � --a0%� _ �-1r Cent. Tester No. --"�7� Date i � �- /O
Gauge # ��,'`� ��' �' � -? q
Date Iast accuracy tested � Z / ��
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy