2013_1024CHECK ONE:
IRRIGATION X DOMESTIC
FIRELINE
BACIOi LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
�t ,
NAME OF PWS: t ' 1 + e, 5c6l �orl�,
PWS I.D. #
LOCATION OF SERVICE: ) IV i Aes n
The back -Low 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
i
Manufacturer 4 Size '
Model Number Located At CQ 12r ¢J
Serial Number
The above is certified to be true.
Firm Name pet l
Firm Address
Certified Tester DQU t A
Cot Taster No. 1JP�6�sg Date d 3
Gauge # Z5&t)o
Date last accuracy tested q � L -3—
White — Customer's Copy
Yellow — City Copy
Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check (:.Q
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
RP- _.psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
_ psid
osid
RP sid
The above is certified to be true.
Firm Name pet l
Firm Address
Certified Tester DQU t A
Cot Taster No. 1JP�6�sg Date d 3
Gauge # Z5&t)o
Date last accuracy tested q � L -3—
White — Customer's Copy
Yellow — City Copy
Pink — Tester's Copy