2013_0905 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACTOLOWmPREVENTION ASSEM 3LLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ! I ) 1 1=
PWS I.D. #
LOCATION OF SERVICE: 0c) I�Pi rrb[
The bacidiow 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
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
!'
Model Number
Serial Number
C+�Ob
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
�P
Size Z,_ 0� ,, �1" �
Located At 1 'c �1 in S`.� wl
P ' U1,
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested ? %3
Certified Testa I
Cat Testa No. n-75 ate ` L-54S
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
I7��el
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
_ osid
,-. id
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
-9ep [a +-e.
and
C (yet. k
Materials
Used
Test After
Rep *
DC- Closed
Tight ,�
RP sid
Closed Tight I0
i ;
Opened at
nsid
Opened at
nsid
,_nsid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested ? %3
Certified Testa I
Cat Testa No. n-75 ate ` L-54S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy