2013_0905 (4)CIIECK ONE:
IRRIGATION_ DOMESTIC FIRELINE
BACKFLOW REVENTION ASSEMBLY 1TEST AND MAINTENANCE REPORT
NAME OF PWS: AU 4) A 2x� -tGtr
PWS I.D. #
LOCATION OF SERVICE: I CJ • fyIGof c-
�O
The bacaow 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
"�O Double Check Valve
Manufacturer (,j a-4-!,
Model Number 00-1 r*'\
Serial Number 8 -z,1 ?1q
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size _ZY
Located At Ct 4e-y\
The above is certified to be true.
Firm Name Cj�je C IS Certified Tester - t C4
i '� tl
Firm Address 3 03 '� �' Cat Tester No. Date
Gauge # -Z,0M
Date last accuracy tested 1Vi 9 5 1:5
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 : `F
2nd Check " M
Initial Test
Q
DC- Closed
Tight
RP -_psid
Closed Tight ¢C
Leaked C3
Opened at
psid
Opened at
pSid
nSid
y
Leaked ❑
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight O
Opened at
.�osid
Opened at
nSid
_s Sid
RP Sid
The above is certified to be true.
Firm Name Cj�je C IS Certified Tester - t C4
i '� tl
Firm Address 3 03 '� �' Cat Tester No. Date
Gauge # -Z,0M
Date last accuracy tested 1Vi 9 5 1:5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy