2012_1109 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACT{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:' '° `�L1
PWS I.D. #
LOCATION OF SERVICE: t _
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 Size
Model Number Located At
Serial Number ' f
The above is certified to be true.
Firm Name T el
Firm Address l Q� �►" fa �-ri�
Gauge # _ QOM
Date last accuracy tested Ltz,
V...._.
Cent Tester No.
Date 10017,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMMLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check- �-,0
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name T el
Firm Address l Q� �►" fa �-ri�
Gauge # _ QOM
Date last accuracy tested Ltz,
V...._.
Cent Tester No.
Date 10017,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy