2010_1106c
CHECK ONE=
IRRIGATION
ll0 M ESTIC
FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS: �- ��-�v ;y Cry o O C`� � �_ �z ; �, ;-� �.• r i"
PWS I_D- #
LOCATION OF SERVICE: _� l =� �� �n Yc; r!J► �1r .
The back-flow prcvmtzon assembly detailed below has bem tested and maintained as required by TNRCC
rcgulatiotts and is certified to be operating within acceptable parameters_
'TYPE OF ASSEMBLY
o Rcduc„ -d Pressure Principle O Pressure Va�°uL Breaker
Double Check Valve e Atmosphere Vacuum Breaker
Manufacttser ��✓:��`� ` =� Size
Model Number ;��b7 Y1'1 1 % Located At I i �.r� l-� A-S-r �' t lF�.(�
Serial Number � � � y�
The above is certified to be true.
Firm Name r()(1 P� 1 ' ,S ' D -
Firm Address { =50� l�rct n�i � f'✓
;�'"- gauge # �.�"��� �.
bate last accuracy tested / �-
`c'f'�% ��r✓
White - Customer's Copy
Certified Tester /� . 1�'7 r (�/
Ccrt_ Tester No_ �'PC,Y,Y�ln7.� Date f G
Yellow -City Copy
Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE1�iBLY
PRESSURE VACUUM BFZF,a7.'FR
Double Check V aloe Assembly
lsf Chec3:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Ti�hL a
Leaked a
psid
osid
RP- osid
Leaked o
Did not Opm o
Leaked O
Rcp arts
and
MatcriaLs
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opined at
osid
Repair
Tight o
osid
psid
RP sid
The above is certified to be true.
Firm Name r()(1 P� 1 ' ,S ' D -
Firm Address { =50� l�rct n�i � f'✓
;�'"- gauge # �.�"��� �.
bate last accuracy tested / �-
`c'f'�% ��r✓
White - Customer's Copy
Certified Tester /� . 1�'7 r (�/
Ccrt_ Tester No_ �'PC,Y,Y�ln7.� Date f G
Yellow -City Copy
Pink - Tester's Copy