2011_0623CHECK ONES
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY TE5T AND MAINTENANCE REPORT
NAME OF FWS:
PWS I.D. #
LOCATION OF SERVICE:
The bacicflow prevention assmably detailed below has been tested and maintaiaed as requited by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pressurc Vacutmi Breaker
�7 Double Check Valve D Amaospherc Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is ce:-tificd to be true.
Firm Name ,,,_�����`I\ ��_ ��' -.: Ca-tifiod Tester
Firm Address ''��b� V�1(?r:1/�Gtx9�`-# Ccrt Tester No.
Gauge # � �OC�(?
Date Iast accuracy tested � �-� , � �;
Date
White - Customer's Copy Yellow -City Copy PirOc - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACWM BR> =�►�'R
Doublc Check Valve Assembly
1st Cheek
2nd Chekl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Tilt �
Lcakcd o
psid
osid
RP- osid
Leaked o
Did noc Open n
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opined at
_osid
Repair
Tight o
osid
osid
RP sid
The above is ce:-tificd to be true.
Firm Name ,,,_�����`I\ ��_ ��' -.: Ca-tifiod Tester
Firm Address ''��b� V�1(?r:1/�Gtx9�`-# Ccrt Tester No.
Gauge # � �OC�(?
Date Iast accuracy tested � �-� , � �;
Date
White - Customer's Copy Yellow -City Copy PirOc - Tester's Copy