2012_1109CHECK ONE:
IRRIGATION_"* \ DOMESTIC FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
:700 S ' "-T() N
The back-low 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 1^ e- b co Size
Model Number s lJ —o Located At ' 5 `%
d�
Serial Number
(A�-��
The above is certified to be true.
Firm Name
Fins Address
Gauge # Z,5�?XO
Date last accuracy tested 1 �'
Certified Testa + �C
Cat Testa No. t, h',n 7�O Dace �l 9
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
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 o
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
^osid
9 7
RP- ___psid
Leaked ❑
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Fins Address
Gauge # Z,5�?XO
Date last accuracy tested 1 �'
Certified Testa + �C
Cat Testa No. t, h',n 7�O Dace �l 9
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy