2012_1116CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: r -I 'SPY
PWS I.D. #
LOCATION OF SERVICE: r
The bacldlow 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 1A)ot-++s Size
Model Number Q —� Located At
Serial Number L4
Test After DC- Closed Closed Tight ❑ Opened at Opened at osid
Repair Tight ❑ psid oSid
RP sid
The above is certified to be true.
Firm Name �T ; 1 Certified Testa � C
Fins Address i �� �`�' f4(44[ty CY Cat Taster No.
Gauge # "766000
Date last accuracy tested Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEILY
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
Tight ❑
Leaked ❑
psid
oSid
Q�7
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight ❑ Opened at Opened at osid
Repair Tight ❑ psid oSid
RP sid
The above is certified to be true.
Firm Name �T ; 1 Certified Testa � C
Fins Address i �� �`�' f4(44[ty CY Cat Taster No.
Gauge # "766000
Date last accuracy tested Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy