2012_1116CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: (,,QQ0P1 ; I ��,�., C yl 4
PWS I.D. #
LOCATION OF SERVICE: ` 1C,
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
1W Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer e- L
Model Number S- 5^o
Serial Number 0 1) C C,- '
Size
Located At
The above is certified to be true.
n e J_ r &111eo-i Firm Name —
Firm Address l ::?> Cert. Tester No. 6RQM Date / �n
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 ❑
Opened at
Opened at
nsid
Tight ❑
RP- pSid
Leaked ❑
pSid
_ ^nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
n e J_ r &111eo-i Firm Name —
Firm Address l ::?> Cert. Tester No. 6RQM Date / �n
Gauge #
Date last accuracy tested__
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy