2010_1110CIIECK ONE.
IRRIGATION DOMESTIC
FIRELINE
BACICFI.OW PREVENTION ASSEA�LY TEST AND MAIl�ii'ENANCE REPORT
NAME OF PWS: �- t^�Tp(Je 1( (►'1 ;c�d le. s e. h 1 Al �r -� �
PWS I.D. # ` -'
LOCATION OF SERVICE: i � Q�es � QC�
The bacicflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�-' Reduced Pressure Principle � Pressure Vacutms Breaker
�" Dl�ou((ble ��C \heck Valve � Atmosphere Vacuum Breaker
Manufacturer W Q �'"►-S � ��
Size G + 1 � / r
Modci Number � of rYJ �� fs?T Located AL J O U ?' �` s � d � OT ►^
Serial Number � S � � / y
The above is ccr'tified Lo be true,
(r�} r
Firm Name -�=' L 5 .� Certified Tester Q� • �) f'/7
Firm Address �� `� fYJ� E'r l.� i' Celt Tester No. !- 'p������ Date % � D /d
Gauge # ��J'
Date last accuracy tested �
�/� � /,�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaKI?R
Double Check Valve Assembly
1st Chek:
2nd Cheri:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
�Lj�%
DC- Closed
Tilt �
RP -_� std
Closed Tight a
Lcalcd o
Opened at
psid
Opened at
__psid
_psid
��� a
Did not Open o
Leaked o
�P�
and
Materials
Used
Test After
Repair
DC- Closed
Tight �
Closed Tight o
Opened at
nsid
Opened at
psid
psid
RP std
The above is ccr'tified Lo be true,
(r�} r
Firm Name -�=' L 5 .� Certified Tester Q� • �) f'/7
Firm Address �� `� fYJ� E'r l.� i' Celt Tester No. !- 'p������ Date % � D /d
Gauge # ��J'
Date last accuracy tested �
�/� � /,�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy