2013_0906 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
t
NAME OF PWS: �O�OEI 1 s-
PWS I.D. #
LOCATION OF SERVICE: 1 oc) 1 4
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.
O Reduced Pressure Principle
Double Check Valve
Manufacturer � � 60
Model Number '^p
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size
Z'
Located At 4 d to c-e P-1p
The above is certified to be true.
Firm Name T ` y Certified Tester l
t3031�c�
Firm Address 1 V Cert. Tester No. 91013
Gauge # /5�p,'
Date last accuracy tested 1 5 ( 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
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
�00i_ j
Tight ❑
lz psid
Leaked c
Leaked a
psid
_ oSid
Did not Open o
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight D
psid
oSid
RP sid
The above is certified to be true.
Firm Name T ` y Certified Tester l
t3031�c�
Firm Address 1 V Cert. Tester No. 91013
Gauge # /5�p,'
Date last accuracy tested 1 5 ( 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy