2013_1024C
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: of\ W o0 Q U t P. m eAorq
PWS I.D. #
LOCATION OF SERVICE:
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
7 Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Gjo- 4-,s
Model Number
Serial Number 'i
Size
Located At
The above is certified to be true.
Firm Name ! I Certified Tester
Film Address l 303 (,Jra► f'!i (,-t C«t Tester No. ate
Gauge #
Date last accuracy tested
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 a
Opened at
Opened at
osid
�j
Tight D
RP- .,psid
Leaked Cl
psid
osid
Leaked r:
Did not Open ❑
Leaked ❑
Repairs
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 ! I Certified Tester
Film Address l 303 (,Jra► f'!i (,-t C«t Tester No. ate
Gauge #
Date last accuracy tested
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy