2013_1105CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: A(I�A�p E l eme n4r,,
PWS I.D. #
LOCATION OF SERVICE: 0' _ ; m nhrc c -)
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
F- Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size T"
Model Number Q 7 :] m 1 Q"T_ Located At C) 4e r
Serial Number A V
The above is certified to be true.
Firm Name f zip ap ! ��i `�� Certified Tester )- .
Firm Address l '3'03 L.-1 K Cert. Tester No. Date i
Gauge # --7 G7d0D
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
osid
�at
Tight ❑
u -_psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open 11
Leaked C3
Repairs
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 f zip ap ! ��i `�� Certified Tester )- .
Firm Address l '3'03 L.-1 K Cert. Tester No. Date i
Gauge # --7 G7d0D
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy