2013_0613 (13)CHECK ONE:
IRRIGATION DOMESTIC
1MV5-;F4TQFZ'N
CTIT OF COT-'Pl,-,I..L
PWS I.D. 4
LOCATION OF SERVICE:. 0 4 l
Ile back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
cegulations and is ccrufied to be operating within acceptable parameters.
C
Reduced Pressure Principle
C Pressure Vacuum Breaker
�
Double Check Valve
0 Atmosphere Vacuum Breaker
Manufacturer
size
Model Number
Located At
t,. C, e ) L
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check-
2nd Check
Relief Valve
Air Inlet
Check Valve
initial Test
DC-Closed
Closed Tight
12
Opened at
Opened at
psid
Tight ❑
Leaked
❑
psid
osid
RP- psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
e,
and
Materials
Used
After
Test Aft
Closed Tight
E3
Opened at
Open ed at
psi
Repair
Tight ❑
Sid
Sid
I
RP . . ..........
. . .. . . .. ..............
mmaasid
The above is certified to be true.
Firm Name
Certified Test=
J; pe)0'a o &
Firm Address /� o do x ;7 7 T-&t Tester No. Date
Gauge # ( , 0 `%' 1 90
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy