2013_0906 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
r n, 1
NAME OF PWS: 0 Q Q e I `
PWS I.D. #
LOCATION OF SERVICE: Cc
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 ❑ Atmosphere Vacuum Breaker
Manufacturer �f_J C.D Size `
Model Number 5 sib Located At 2 0- �o ti}o,-4L
Serial Number A 0"7 56 (4`
The above is certified to be true.
Firm Name n -o p P S
Firm Address i7j0� t,Jrot!"c�1���
Gauge #r�
Date Last accuracy tested ' '1 7j
Certified Tester DCL U 1 J t- ,Ya 1
Cat. Tester No. OM 0% Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check ? , q
I 2nd Check -
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Tight ❑
RP- ----- id
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked Cl
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name n -o p P S
Firm Address i7j0� t,Jrot!"c�1���
Gauge #r�
Date Last accuracy tested ' '1 7j
Certified Tester DCL U 1 J t- ,Ya 1
Cat. Tester No. OM 0% Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy