2013_0905 (2)CHECK ONE:
IRRIGATION_ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: mcc m IJ i> J kn'
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.
0 Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
r r
Size .Z(t j
Located At F-r'0 " 14 0'
LK
The above is certified to bei true.
Firm Nacre 1
Firm Address
°- Gauge ll C- _0
Date last accuracy tested
r
Certified Tester b- �-n 1Le,!:j
Cert. Taster No. Kd. W _ Date 21-GL-5
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 Z. Z-
2nd Check
Initial Test
DC- Closed
Tight i
Closed Tight
Leaked o
Opened at
psid
Opened at
psid
_pSid
RP- __psid
Leaked D
Did not Open o
Leaked-
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
psid
Opened at
pSid
psid
RP sid
The above is certified to bei true.
Firm Nacre 1
Firm Address
°- Gauge ll C- _0
Date last accuracy tested
r
Certified Tester b- �-n 1Le,!:j
Cert. Taster No. Kd. W _ Date 21-GL-5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy