2011_1219 (3)i���
CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
NAME OF PWS�L L..,c�P � 1 � � ��� 5��� NANCE REPORT
PWS I.D. #
LOCATION OF SERVICE: "'f�lV �n 1 /\a � i�t( :� �-°
The bacl. -flow prevcation assembly detailed below has beea tested and tnaintaiaed as zzquuzd by TNRCC
rogttlarioas aad is cerdficd to be operating within acceptable paratneu:rs_
rn`��xa7�� u����:7
"II Ruiuced Pressure Principle D Pressure Vacuum Breaker
� Doubble CCheck Valve C Atmosphere Vacuum Breaker
Manufacturer ��]�tjT,T/ -`17 � L Size % �l� L / /
Model Number � � li' /• i � [9 //C� Located At �� /14� f� / � � S/? ®� .
serial Number � `733 ��10
The above is certified to be tru�e. -^
Firm Name -+- • S•� Certified Tester Q V ! � � `' � '�
Firm Address (��tGi� � -<-r �. Cut Tester No. ���" Date % � ��
Gauge # �� ���% n
Date last accuracy tested �7 �� /
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJiJM B��'A�'R
Doubic Cheek Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Ti°�t �
Leaked a
psid
osid
�Cj'
RP- osid
Leaked c
Did aot Open o
Leaked o
�P�
and
Materials
Used
Test AH�er
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be tru�e. -^
Firm Name -+- • S•� Certified Tester Q V ! � � `' � '�
Firm Address (��tGi� � -<-r �. Cut Tester No. ���" Date % � ��
Gauge # �� ���% n
Date last accuracy tested �7 �� /
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy