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2012_1116 (2)cli C CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF 01/) (� �1 ( E 11'1 PWS I.D. # LOCATION OF SERVICE: The bacltilow prevention assembly detailed below has been tasted 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 1- CAD C U Size Model Number© Located At Serial Number o (,- The above is certified to be true. Firm Name f� ! Certified Tester Q U Firm Address r r Cent. Tester No. ?MQb75& Date ° �!'�� Z- Gauge # ? 588 r,)o Date last accuracy tested Z- White - Customer's Copy Yellow - City Copy Pink - 'T'ester'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 �j Tight ❑ RP- pSid Leaked ❑ psid oSid Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at psid Repair Tight ❑ osid pSid RP sid The above is certified to be true. Firm Name f� ! Certified Tester Q U Firm Address r r Cent. Tester No. ?MQb75& Date ° �!'�� Z- Gauge # ? 588 r,)o Date last accuracy tested Z- White - Customer's Copy Yellow - City Copy Pink - 'T'ester's Copy