2013_1105 (2)CHECK ONE:
IRRIGATION A
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �C' n S�Ya NJ
PWS I.D. #
LOCATION OF SERVICE: god L�. e.Ao, k G F RD
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
Model Number
Fib C
? -o
,
Serial Number I "1-7%
Size
Located At S
The above is certified to be true.
Firm Name Certified Tester
Firm Address i Y- Cent. Tester No. Datet 1115113
Gauge # -Z5 8000
Date last accuracy tested i 5 13
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 4
2nd Check
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight o
Leaked o
psid
osid
RP -, osid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address i Y- Cent. Tester No. Datet 1115113
Gauge # -Z5 8000
Date last accuracy tested i 5 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy