2013_1105CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: M(x
PWS I.D. #
LOCATION OF SERVICE: ::3nn ml l Li r-QU I(
The bacUow 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 F' �t i) Size {
Model Number Located At p ISy" sckml
Serial Number 4° a'� Q�! P , CV, -
The above is certified to be true.
„ Firm Name
r S _
Firm Address % �� '' 0,/- �✓
Gauge #
Date last accuracy tested
Cawed Tester .�� , 1 _
Cat Tester No. t
FDate
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
psid
Tight ❑
RP- __psid
Leaked o
psid
osid
y
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
rie p ice
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
psid
Opened at
psid
nsid
RP sid
The above is certified to be true.
„ Firm Name
r S _
Firm Address % �� '' 0,/- �✓
Gauge #
Date last accuracy tested
Cawed Tester .�� , 1 _
Cat Tester No. t
FDate
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy