2013_1024 (3)CHECK ONE:
C) IRRIGATION DOMESTIC
FIRELINE
BACEFLOW PREVE MON ASSEIM 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS: t,,2W N�hTt✓ �i enTar`�
PWS I.D. #
LOCATION OF SERVICE: AJ I 1
The baclflow 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
Serial Number '
Size
Located At -' c��►
T—'
The above is certified to be true.
Do 4/�2
Firm Name -- e l l -� 5 V Certified Tester y ' d � � Firm Address { 3 �`�`'�,� Cert. Tester No. 67� Date 7-m3
.� Gauge # 7 50wo
Date last accuracy tested .I r.>' 0
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 '7
2nd Check � ' �
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
sid
Leaked ❑
psid
psid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Dsid
Repair
Tight o
psid
psid
RP sid
The above is certified to be true.
Do 4/�2
Firm Name -- e l l -� 5 V Certified Tester y ' d � � Firm Address { 3 �`�`'�,� Cert. Tester No. 67� Date 7-m3
.� Gauge # 7 50wo
Date last accuracy tested .I r.>' 0
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy