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2013_0906 (8)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: w �n C teMey4ar PWS I.D. # LOCATION OF SERVICE: Ze© ' t ooe r 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 Cl Reduced Pressure Principle 0 Pressure Vacuum Breaker Double Check Valve C Atmosphere Vacuum Breaker Manufacturer 1ebe-o Size +r Model Number 75-D Located At Serial Number ' 1065g 3 The above is certified to be true. /11'_, Firm Name i e l 1;:r75 � Certified Testes 1 Firm Address Lj� tr- Cent. Taster No. Date Gauge # ()00 Date last accuracy tested 15J 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 flsid Tight o Leaked o psid osid lZ -_psid Leaked C7 Did not Open D Leaked o Repairs and Materials Used Test ABer Repair DC- Closed Tight o Closed Tight 0 Opened at psid Opened at psid psid RP sid The above is certified to be true. /11'_, Firm Name i e l 1;:r75 � Certified Testes 1 Firm Address Lj� tr- Cent. Taster No. Date Gauge # ()00 Date last accuracy tested 15J White - Customer's Copy Yellow - City Copy Pink - Tester's Copy