2010_1110 (2)CIIECK ONE.
IRRIGATION D011�SESTIC FIRELINE
BACKFI..OW PREVENTION ASSEl►�LY TEST AND MAINTENANCE REPORT
NAME OF PWS.
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assembly detailed below has bem tested and maintaiaed as required by TNRCC
re2ulaaons and is certified to be operating within acceptable paratnetcs.
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pressure Vacutnz+ Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
��� �l�
Firm Name _ _.<= �: ; � +' i -'- _ -? � • Certified Tester �
Firm Address l � C � � l �� li� �, L-i 1' Cent Tester No. � P��'Sg Date � � / /v /�
Gauge # ���OCX�
Date last accuracy tested LD (yl � �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEM�iLY
PRESSURE VACUUM BRFarr�R
Double Check Valve Assembly
1st Checlt
2nd Chekl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight a
Opened at
Opined at
osid
Tilt C7
Leaked a
psid
osid
RP- osid
Leaked o
Did not Opm �
Leaked �
�p�
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opined at
Opined at
o_ sid
Repair
Tight �
nsid
osid
ItP sid
The above is certified to be true.
��� �l�
Firm Name _ _.<= �: ; � +' i -'- _ -? � • Certified Tester �
Firm Address l � C � � l �� li� �, L-i 1' Cent Tester No. � P��'Sg Date � � / /v /�
Gauge # ���OCX�
Date last accuracy tested LD (yl � �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy