2011_0422 (14)CIIEC,K ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D- #
LOCATION OF SERVICE: � "�� _ .'� ,
The backtlow prevention assembly detailed below has been tested and maintained as required by TCCQ
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
a Reduced Pressure Principle o Pressure Vacuum Breaker
t� ' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size �=—� �
Modei Number
Seriai Number
Located At
'•`
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��R
Double Check Valve Assembly
1st Checi:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
s.
Initial Tat
DC- Closed
Closed Tight D'
Opened at
Opened at
vsid
Tilt e3'"
Leaked C7
psid
osid
RP- vsid
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
vsid
Repair
Tight o
osid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address fl
Gauge #
Date last accuracy tested
Certified Tester � -
Cert. Tester No_ - � ._ * " Date -
White — Customer`s Copy Yellow —City Copy Pink — Tester's Copy