2012_0420 (9)CfIECK ONE
IRRIG A TIO N�_ DOMESTIC FIRELINE
BACI�'LOW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: �-i ?`� L''F- lc�n�� =-�i
PWS I.D. #
LOCATION OF SERVICE: L�(,O �l l/ \ C� L°�1
The backtlow prevention assembly detailed belo��� has been teacd and maintained as required by TCFQ
rc��ulations and is certil�icd to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Reduced Pressure Principle C Pressure Vacuimm Breaker
Doubrrle Chock Valve � Ammosphere Vacuum Breaker
Manufacturer WCc `T � 5 Size r-� „
Model Number d O �/ `W1 l Located At � %t✓� e'r "'�� L`� �jTit � e �
Serial Number f7 t� f7C� ���
Gauge # 3 a t� � /
Date last accuracy tested Sl /
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE11 -fBLY
PRESSURE VACLTCTM BRFa�'FR
Double Cher3c Valve Assembly
1st Checl: 2nd Check Relief Valve
Air Inlet Cheek Valve
Iaitial Test
DC- CIoscd Closed Tight �
Opened at
Opined at
osid
Tilt Q� Leaked o
RP -�psid � - ��
osid
osid
1 -caked o
Did not Opm o
Leaked �
Repairs
and
Materials
used
Test ARa
DC- Closed Closed Tight o
Opened at
Opened at
osid
Repair
Tight D
osid
osid
RP sid
The above is
certified to be true. 7 Z-l>
Firm Name �
T � .+�J �� �'�. Certified Testa _�
W G -/ wG ��yt v//► �*'
Firm Addt�ess
/L�
PC7 'Qo x /d,�G�G M ec -�Y Cent Tester No. � �i�Od 9�J� Date � /a0% / �
Gauge # 3 a t� � /
Date last accuracy tested Sl /
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy