2011_1219CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI�LOW PREVENTION�ASSEMBLY TEST AND M.4Il�TI'ENANCE REPORT
NAME OF PWS: t t>n�P_�' i � 1 i�C�'E- Wit. ��DD� E_
PWS I_D. # ,, rr ,.� n l
LOCATION OF SERVICE: "t � O I Y f O � �� nQb � -r L�i� it e-
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
reQUlations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
G Reduced Pressure Principle � Pressure Vacutma Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is cer'tifiod to be true.
Firm Name ` � - � --Z. S Certified Tester
Firm Address ` 3 bra, -,c��� ►,- Cent Tester No. Dau
Gauge # zS��
Date last accuracy tested "/ 3
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BRFAKAR
Double Cheek Valve Assembly
1st Cheek
2ud Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Tight D
Leaked O
psid
o_sid
RP- nsid
Leaked D
Did not Opm o
Leaked O
Repairs
and
Materials
Used
Test AftJer
DC- Closed
Closed Tight O
Opined at
Opined at
nsid
Repair
Tight [7
nsid
nsid
RP sid
The above is cer'tifiod to be true.
Firm Name ` � - � --Z. S Certified Tester
Firm Address ` 3 bra, -,c��� ►,- Cent Tester No. Dau
Gauge # zS��
Date last accuracy tested "/ 3
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy