2011_0628 (9)CHECK ONE:
IRRIGATION l
DOMESTIC
FIRELINE
BACI(FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backi7ow prevention assembly detailed below has been tested anti maintained as required by TCLQ
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number'
Serial Number H (:� t 11 I `-j
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size
Located At rvfe
Gauge # { ; ( `--% A) "
Date last accuracy tested `> -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
( PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed )
I'-,
l
Closed Tight Opened at
Opened att?sid
Tight , M
Leaked ❑ psid
psid
RP -_Lpsid
Leaked c
�'' i `
Did not Open o Leaked D
Repairs
and
� r
Materials
Used
/
Test Alter
Repair
DC- Closed
Tight � ea
Closed Tight , f Opened at
Opened at osid
.
/ ______ psid
I
�— psid
RP sid
The above is cerrifled to be true.
Firm Name, -'f` r �4 ti �� , tit Certified Tester �
/
`� ti's•° -, �-•1� � t � �-
Firm Address
_ `' L A 7 7 `J3c�
-' t G, l,�tl,t Testa No. ' fin'` ;t Date ' Z c
Gauge # { ; ( `--% A) "
Date last accuracy tested `> -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy