2013_0905CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: l..m�QC- SSO e',) 6
PWS I.D. # ff
LOCATION OF SERVICE: ,�t l atoi, {
The back-Low 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 ❑ Atmosphere Vacuum Breaker
Manufacturer Ve.6 LO Size Z
Model Number ETD Located At �
Serial Number A (72 �io—i
The above is certified to be true.
Firm Nameed K I l LSD Certified Tester _
Firm Address 503 Cent Taster No. Date 2 4 -IS
Gauge # 7Geovo
Date last accuracy tested _q-k-I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check: , 3
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight ❑
RP- __ —psid
Leaked ❑
psid
_oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Nameed K I l LSD Certified Tester _
Firm Address 503 Cent Taster No. Date 2 4 -IS
Gauge # 7Geovo
Date last accuracy tested _q-k-I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy