2013_0906 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: _ 0 (z C
The backflow 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 �7!'kn t n Size
Model Number __- �D �
Serial Number A C) -7 3-1-1
Z''
Located At 3 01( �
The above is certified to be true.
Firm Name pe` Certified Tester 1) , ba e'6 V
Firm Address _ O3 �f Cem Tester No. ,,.A 0(fl Date t'o 1/3
Gauge #
Date last accuracy tested Q � 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2, c(
2nd Check 3
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight L4'
Opened at
Opened at
osid
Tight ❑
RP- pSid
Leaked ❑
psid
oSid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight ❑
psid
osid
��
RP sid
The above is certified to be true.
Firm Name pe` Certified Tester 1) , ba e'6 V
Firm Address _ O3 �f Cem Tester No. ,,.A 0(fl Date t'o 1/3
Gauge #
Date last accuracy tested Q � 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy