2013_0906 (7)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: l Q4P_1(
PWS I.D. #
LOCATION OF SERVICE: _ j (low ba\,1
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 ❑ Atmosphere Vacuum Breaker
Manufacturer ° C� Size t
Model Number �� Located At '7 b
Serial Number
The above is certified to be true.
Firm Name Certified Tester, 1 1 len
Firm Address 1/ Cent. Tester No.
-7 9Date
Gauge #�
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEIIMLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check: 7,
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight V-
Opened at
Opened at
psid
Tight ❑
Leaked ❑
psid
osid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked C3
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name Certified Tester, 1 1 len
Firm Address 1/ Cent. Tester No.
-7 9Date
Gauge #�
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy