2013_1105CHECK ONE:
IRRIGATION J( DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
(�
NAME OF PWS: � 1'h i r1 i AM-36 o n Ni)
PWS I.D. # n
LOCATION OF SERVICE: 200 S p
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 ReU C c) Size
Model Number
Serial Number
Located At
Z
The above is certified to be true.
Firm Name i S� Certified Tester s A
Firm Address 1--0 � J C 1 �` r Cent Taster No. ` Date 5 13
Gauge # 0 �%
Date last accuracy tested S /: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 -2,4
2nd Check Z,
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
Tight.
RP- _- _,psid
Leaked ❑
nsid
_� sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__psid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name i S� Certified Tester s A
Firm Address 1--0 � J C 1 �` r Cent Taster No. ` Date 5 13
Gauge # 0 �%
Date last accuracy tested S /:3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy