2011_0627CHECK ONE:
IRRIGATION
BACT�3.OW
NAME OF PWS:
PWS I.D. #
DOMESTIC
ASSEMBLY
LOCATION OF SERVICE: ��� S ^ f J ell "*`!� O'1 � P
FIRELINE
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The bacl. -flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
`❑
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
�Q
TYPE OF ASSEMBLY
� Pressure Vacutmg Breaker
o Atmosphere Vacuum Breaker
��_ % f'�% � ' t�
►� i rf 3�
Size
Located At
._
I
.. -
Date last accuracy tested iO �� �,�
Whit¢ - Customer's Copy Y¢Ilow -City Copy Pink - T¢st¢r•s Copy
REDiJCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUCTM BRF'AKFR
Double Check Valve Assetnbly
1st Cheek
2nd Checl:
Relief Valve
Air Inlet
Chec3c Valve
Initial Test
DC- Closed
Closed Tight o
Opcaed at
Opened at
osid
'_ jQ�
,j/
Ti�i o
RP- osid
Leaked o
psid
osid
Lcal:ed o
Did aot Opm o
Leaked Q
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight O
Opened at
Opined at
osid
Repair
Tight D
osid
osid
RP sid
._
I
.. -
Date last accuracy tested iO �� �,�
Whit¢ - Customer's Copy Y¢Ilow -City Copy Pink - T¢st¢r•s Copy