2013_1024 (4)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 1 ow o
PWS I.D. #
LOCATION OF SERVICE: � 9
t
r'
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 ASS:
Q Reduced Pressure Principle Q
Double Check Valve Q
Manufacturer Size
Model Number �SS�y Located At
Serial Number L4
LIMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
G'
The above is certified to be taste.
Firm Name O Certified Tester
Firm Address (�TQ F' Cert. Testa No. Date ,� 7 /.3
Gauge # -Z6p 00 0
Date last accuracy tested
Lq4IL
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 Q
Opened at
Opened at
psid
r
��EjGj'
Tight
RP -_psid
Leaked Q
psid
osid
Leaked ❑
Did not Opcn ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight
p sid
pSid
RP sid
The above is certified to be taste.
Firm Name O Certified Tester
Firm Address (�TQ F' Cert. Testa No. Date ,� 7 /.3
Gauge # -Z6p 00 0
Date last accuracy tested
Lq4IL
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy