2013_1024 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSE 33LY TEST AND MAINTENANCE REPORT
NAME OF PWS: C64n n tA) 0 0 0 creek
PWS I.D. #
r_
LOCATION OF SERVICE:
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
R Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer k1l4
Size
t
Model Number t_(,�''i M ` Located At FrOOA n-
Serial Number 27 th
The above is certified to be true.
Firm Name C t l —5-5D Certified Tester ^ uv u P-11 (I lei
Firm Address t3O3 Or +� Cert. Tester No. S Date E r) t �7 q 1
Gauge #����
Date last accuracy tested j 1!5 h:5
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 ❑
Opened at
Opened at
osid
Tight ❑
RP -sid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name C t l —5-5D Certified Tester ^ uv u P-11 (I lei
Firm Address t3O3 Or +� Cert. Tester No. S Date E r) t �7 q 1
Gauge #����
Date last accuracy tested j 1!5 h:5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy