2013_0905CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIU'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: n Mo(.Xk,rcib {Y-4
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer deb e,G
Model Number
Serial Number H E)
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At 1- ra 0� sc ica
C4/,
The above is certified to be true.
Firm Name I (�� Certified Tester
Firm Address � t✓ Cem Tester No.
Gauge # 7,5 U)Q
Date last accuracy tested
Dam y I S /3
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 'F,
Opened at
Opened at
psid
Tight .D
RP —_psid
Leaked ❑
Leaked o
psid
osid
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name I (�� Certified Tester
Firm Address � t✓ Cem Tester No.
Gauge # 7,5 U)Q
Date last accuracy tested
Dam y I S /3
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy