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2011_1219 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFi.O /W PREVENTION �,.S,SENIBiLY TES jT�AN }D MAINTENANCE REPORT NAME OF PWS: �- � -C�O[� �P_� � � � � � le �:, .---!' \Q� I �R S" i PWS I.D. # �} 1^ LOCATION OF SERVICE: �'�'�� � t hC' �!I'�CJ 1 l't� �Vl � The bacl�low prevention assembly detailed below has been tested and maintained as requirad by TNRCC regulations and is certified to be operating within acceptable parameters_ TYPE OF ASSEMBLY Q Reduced Pressure Principle � Pressure Vacuum Breaker 0 Double Check Valve o Atmosphere Vacuum Breaker Manufacaaer (�,� -,S Size O% �Z Modci Number �q 1 T 1 Z- !`�� Located At (�lrin C� A�-t '`J�t °JT. Cif DS�'; Scrim Number � �3 The above is certified to be true. Firm Name Q � Certified Tester , � , Firm Address « ©� l9 _3 Y'Q1'�i ,i i Cent_ Tester No. ���0 Date � / /% ,ir +'� Gauge # ����y� (� ��j 17ate last accuracy tested -( /.� �� White - Customer's Copy Yellow -City Copy Pink - Testers Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Check 2ud Checl: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight o Opened at Opened at osid � Lj� Tight C7 RP- +, , osid Leaked a - psid osid I -caked 0 Did not Open 0 Leaked o �Pa� and Materials Used Test After DC- Closed Closed Tight a Opened at Opened at osid Repair Tight � asid osid RP sid The above is certified to be true. Firm Name Q � Certified Tester , � , Firm Address « ©� l9 _3 Y'Q1'�i ,i i Cent_ Tester No. ���0 Date � / /% ,ir +'� Gauge # ����y� (� ��j 17ate last accuracy tested -( /.� �� White - Customer's Copy Yellow -City Copy Pink - Testers Copy