2011_0623 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELIN
BACKFLOW PREVEN'T'ION ASSEA'D3LY TEST AND M.daI2�TTENANCE REPORT
NAME OF PWS: �' � n� P 11 ►�Y� , �_.� � P � (" L, c >. -, j � , ; , �, ,
PWS I.D_ #€
LOCATION OF SERVICE: � b D �1 O G1 C i ti^ -; �'? t fC� I� (1
The bacicflow pmmtion assembly detailed below has been tested and maintaiaed as required by TNRCC
regulations and is catificd to be operating within acceptable parameters_
TYPE OF ASSEMBLY
II Reduced Pressure Principle � Pressure Vacuttan Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name 1 — S � � Certified 'fester
Firm Address l � Ci � Lw jy r'Z '�� `Geri Tests No. ' Date ��'
Gauge # <�
Date last accuracy tested � Z� i
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
$RF'AT�'R
Double Check Valve Assembly
1st Chec3:
2nd Check:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Tilt �
Lcakcd o
psid
osid
RP- osid
Leaked o
Did not Open o
Leaked o
�P�S
and
Materials
Used
Test Af%r
DC- Closed
Closed Tight �
Opined at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name 1 — S � � Certified 'fester
Firm Address l � Ci � Lw jy r'Z '�� `Geri Tests No. ' Date ��'
Gauge # <�
Date last accuracy tested � Z� i
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy