2013_0905 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION A CCEMMLY T AND MAINTENANCE REPORT
NAME OF PWS: e,
PWS I.D. #
LOCATION OF SERVICE: Mf bi � Ln .
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer R6 co
Model Number ( S -b
Serial Number "0 56±k
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size j
Located At
The above is certified to be true. t� i
Firm Name e i � 5D Certified Tester
Firm Address WU e ` Cat Tester No. Date `J
Gauge # 26�
Date last accuracy tested R 5 1 11-3
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: 'L
2nd Check -Z, (.
Initial Test
q�j�Tight
DC- Closed
RP -_psid
Closed Tight A
Leaked o
Opened at
psid
Opened at
psid
_ psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight ❑
Opened at
_ ^psid
Opened at
nSid
nsid
- - -�
RP sid
The above is certified to be true. t� i
Firm Name e i � 5D Certified Tester
Firm Address WU e ` Cat Tester No. Date `J
Gauge # 26�
Date last accuracy tested R 5 1 11-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy