2010_1008CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEMBLY -TEST AND MAINTENANCE REPORT
NAME OF PWS: ' ` _ r1 L i �: i �`l�. r1 j� .tr � -1
PWS LD_ #
LOCATION OF SERVICE: � � ' '� k' t, �'-
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
D Rcduc� Pressure Principle o Pressure Va�ctn.*„ Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Maaufactm-er -
Model 1V umber
Serial Number
Size �
Located At �_� i� � '!-� -- a�,E_ ! �
The above is certified to be true.
Fitm Name {- t � ', S � . Certified Tester -S
Firm Address (��� �� `:�Y�A� 1 Y" Cent Tester No_ � � Date _ � -
Gauge # ��g0��
Date last accuracy tested � ��
��29 �/n
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSiJRE PRINCIPLE ASSEMBLY PRESSURE VACUUM
BRFAKF'R
Double Cheek Valve Assembly
1st Cher: r . -�
tad Cheek � 1
Relief Valve Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ®
Opened at Opined at
nsid
•' "•
Tight ®
RP- nsid
Leaked a
psid nsid
I- ealcad �
Did not Opm O
Leaked �
Repairs
and
Materials
Us«i
Test After
DC- Closed
Closed Tight o
Opined at Opined at
nsid
Repair
Tight a
nsid nsid
RP sid
The above is certified to be true.
Fitm Name {- t � ', S � . Certified Tester -S
Firm Address (��� �� `:�Y�A� 1 Y" Cent Tester No_ � � Date _ � -
Gauge # ��g0��
Date last accuracy tested � ��
��29 �/n
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy