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2011_0326CIIECK ONES IRRIGATION DOMESTIC FIRELINE BACI�Z.OW PREVENTION ASSEjMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: � (�(� e �' � i r'�� l �'- _ C �0��� � AST PWS I_D. # LOCATION OF SERVICE:. � O D (%ill o�ic� ►'�'p� � �.- n The bacicIIow pttvmrion assembly detailed below has bees tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters_ C�' Rcducrd Pressure Principle o Double Check Valve Manufacturer �� -�'�� S Modc1 Number fY\ � QT SerialNtmiber '�.�lo TYPE OF ASSEMBLY � Pressure Vacuum Breaker � Atmosphere Vacuum Breaker Size Located AL The above is certified to be true. Firm Name =�ZQt° � \ ` �-s- S ©t Certified Tester ;fit `nt2 � J i � �� C� t C ��a Firm Address 1303(,J�v�ca 1 e►� � ✓ Cert. Toter No.�Y`CX`�1.,`( S� Date � !� Gauge # Z5 Date last accuracy tested ( � 9 � � f'' White - Customer *s Copy Yellow -City Copy Pirilc - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACWM BRFAKRR Double Check Valve Assembly 1st Cheri: 2nd Checl: Relief Valve Air Inlet Cheek Valve Initial Test i' > DC- Closed Ti�i o Closed Tight o Lcal:cd O Opined at - - psid Opined at __nsid nsid alj5 RP- '• nsid Leered o Did not Opm o Leaked o Repairs and Materials Used Test ARer DC- Closed Closed Tight o Opined at Opened at nsid Repair Tight � nsid nsid RP sid The above is certified to be true. Firm Name =�ZQt° � \ ` �-s- S ©t Certified Tester ;fit `nt2 � J i � �� C� t C ��a Firm Address 1303(,J�v�ca 1 e►� � ✓ Cert. Toter No.�Y`CX`�1.,`( S� Date � !� Gauge # Z5 Date last accuracy tested ( � 9 � � f'' White - Customer *s Copy Yellow -City Copy Pirilc - Tester's Copy