2012_1116 (3)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C
PWS I.D. #
LOCATION OF SERVICE: _�(;Z() Mo. e ,`/ i t
The backflow 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-_, C Size
Model Number Located At 014 C? 7 z;, l Qn
Serial Number��
The above is certified to be true.
Firm Name °Pr ' —I S . Certified Tester )✓J • / /!d� ! /C
Firm Address �� Cert. Taster No, 3> Date _Idlh =
Gauge # zla�
Date last accuracy tested /'!—I> Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 7.
2nd Check "'
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
Leaked o
psid
osid
RP —_psid
Leaked ❑
Did not Open D
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name °Pr ' —I S . Certified Tester )✓J • / /!d� ! /C
Firm Address �� Cert. Taster No, 3> Date _Idlh =
Gauge # zla�
Date last accuracy tested /'!—I> Z
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy