2012_0628 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PWS LD. #
LOCATION OF SERVICE: �U' k)L -717; "'Y'f" S%�e � o O
The bacl�low prevention assembly detailed below has bem tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C' Reduced Pressure Principle C Pressure Va�-+n•**+ Breaker
� Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer (�. 1�->' � Size �% z
L /�
Model Number / ��� Located At f Z S / 0� U/ � (�+j� -.� � 5/ N / c_
Serial Number r % y �
The above is certified to be true.
Firm Name -Ol ACCURACY BACKFLOW
. 6
Firm Address RICHARDSON, TX 75083 -0416
Gauge # Q �` °Z� /7z
Date Iast accuracy tested
Certified Tester ;'t-i
Cent Tester No. Date ?�� � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
BRFax�'R
Double Check Valve Assembly
1st Checl:
2nd Check
RelieF Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Tight �
Leaked �
nsid
nsid
RP- osid
Lcal:ed o
Did not Open o
Leaked �
Pairs
and
MatciaLs
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP std
The above is certified to be true.
Firm Name -Ol ACCURACY BACKFLOW
. 6
Firm Address RICHARDSON, TX 75083 -0416
Gauge # Q �` °Z� /7z
Date Iast accuracy tested
Certified Tester ;'t-i
Cent Tester No. Date ?�� � Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy