2013_1024W
CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
Pla ce-
PWS I.D. #
LOCATION OF SERVICE: �a �11 n� �) 0
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 � r ���1 �JS' Size Z`
Model Number f 5o Y-L I Located At '
Serial Number
The above is certified to be true.
Firm Name S� / Certified Testa A`
Firm Address (?J l�Jdl'� tE^�t -+i• �', Cert. Tasty No. ��`�� Date �� Z'7
Gauge # ' Seoo
Date last accuracy tested qJ
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 f✓
2nd Check
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
!
C� l
Tight ❑
RP- psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_� sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name S� / Certified Testa A`
Firm Address (?J l�Jdl'� tE^�t -+i• �', Cert. Tasty No. ��`�� Date �� Z'7
Gauge # ' Seoo
Date last accuracy tested qJ
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy