2013_1105 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF FWS: 4M tI��
FWS I.D. # i
LOCATION OF SERVICE: 'y'n o M 9 IG 1 j"
The back:Cow 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 Lpkc 0 Size Z-
Model Number IR S t. Located At
r--
Serial Number
The above is certified to be true.
Firm Name
Firm Address 1 `S
Gauge #�•y°,:
Date last accuracy tested 0(W3
Certified Tester 1s
Cat Tester •
• . .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check ?. Z
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
osid
sid
a�
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address 1 `S
Gauge #�•y°,:
Date last accuracy tested 0(W3
Certified Tester 1s
Cat Tester •
• . .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy