2010_1008CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACI�Z,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �_l�;�,C�; c:,��- -;:,..
PWS I.D. #
LOCATION OF SERVICE: � ! `- ' ' �. � -
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
0 Reduced Pressure Principle o Pressure Vacua Breaker
!�_ Double Check Valve o Atmosphere Vacuum Breaker
Manufactttter "?' _1 "� Size �
Model Number - ; <� � _ ;, . -r i _ (y _
Serial Number � "� � ' ` -�
Located At r :_ � , � �J F�:' >� c_; �� c � 4L
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE vACWM BREAKER
Double Check V slue Assembly
1st Check "/ 2nd Check Relief Valve Air Islet Check Valve
Initial Test DC- Closed
Closed Tigh[ ti
Opined at Opined at
nsid
Tilt t�
Leaked a
psid nsid
;:•`,' - RP- nsid
I -�akrd �
Did not Opm a
Leaked a
Repaus
and
Materials
Used
Test After DC- Closed
Closed Tight O
Opined at Opined at
nsid
Repair Tight C7
nsid nsid
RP sid
The above is certified to be trot_
' � 1 � ---- � � �.
Fitm Name ` _ -.. E � � E' ' _ -� � L -' Certified Tester l : � � /��a
Firm Address - � :� rr.� ntq �% `` "� r Cert Tester No. 8% dGI'��758 Date U l �'
Gauge # `GS�'�
Date last accuracy tested �o Z 9 / D
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy