2010_1110 (2)CHECK ONE.
IRRIGATION
DOMESTIC
FIRELIN
BACKFLOW PREVENTION ASSEMBLY TEST AND M.A.IN'I'ENANCE REPORT
J M jr.
NAME OF PWS: l__ J f`; (J � � 1 ! s ': � r�,^1 l � �C�� ^ O ` ., k �r
PWS I.D. #
LOCATION OF SERVICE: `� "'
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameu -rs.
TYPE OF ASSEMBLY
� Reduced Pressure Principle o Pressure Va�-trL***a Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number G�i� �` Located At
Serial Number s�
_�
The above is certified to be true.
i..,
Firm Name _� � e11 (\\ 1 Certified T'ater J • '.JC /d 1 ! �
Firm Address ��J�J l��R �` •i ✓ Cent Tesler No. > J��.'10%�gDace � �O �
Gauge # '"S ��� �7Q
Date last accuracy tested �.� G� ! %�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY'
PRESSi_7I2E VACUUM BRF a�'F'R
Double Check Valve Assembly
1st Check
2ted Chekl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
Tilt o
RP- osid
Leaked a
psid
osid
caked c
Did not Opcn �
Leaked o
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tighe o
Opened at
Opened at
osid
Repair
Tight �
osid
osid
RP sid
The above is certified to be true.
i..,
Firm Name _� � e11 (\\ 1 Certified T'ater J • '.JC /d 1 ! �
Firm Address ��J�J l��R �` •i ✓ Cent Tesler No. > J��.'10%�gDace � �O �
Gauge # '"S ��� �7Q
Date last accuracy tested �.� G� ! %�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy