2012_0217 (2)CHECK ONE:
IRRIGATION _ DOMESTIC 1 FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C '1 T )' OF' (70PI'EL L
PWS I.D. #
LOCATION OF SERVICE: I % D I E
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑
Reduced Pressure Principle
❑ Pressure Vacuum Breaker
Double Check Valve
c Atmosphere Vacuum Breaker
Manufacturer �, %lt `��
Size
Model Number _ C�
Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
IL
Double Check Valve Assembly
1st Check I 2nd Check:
Relief Valve Air Inlet Check Valve
DC- Closed Closed Tight )K Opened at Opened at sid
Tight Leaked
❑
RP- -._.__ -psidg
�flsid
Leaked ❑'
Fa:nd�
Did not Open ❑ Leaked ❑
E Auer DC- Closed Closed Tight
ir Tight ❑
❑ Opened at Opened at __nsid
RP sid
_ osid esid
The above is certified to be true.
Firm Name h L17 Cry.( 9M!- -
Certified Tester
ddms
Firm A � .�
,
Cext Tests No. ���,� Date '2'
��. C?UtCI C,� xa �' l►� �
Gauge #r
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy