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2013_1024 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: ame-11 IP C J Cko l NoA- 11 I.D. # LOCATION OF SERVICE: ��C6 \ r Ch 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 c Atmosphere Vacuum Breaker Manufacturer Oak Model Number 00-1 (�) Serial Number X40 ( "i Size z� Located At k Su.) t-- yl � The above is certified to be true. Firm Name t- Certified Tester r L .� t Firm Address ( Cert. Taster Na ' -ice Date �� /� �/� Gauge # (7 / Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly ist Check ? , 2nd Check ' Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight ❑ Opened at Opened at oSid Tight c Leaked o psid oSid RP -_psid Leaked c Did not Open o Leaked a Repairs and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at _� sid Repair Tight o psid oSid RP sid The above is certified to be true. Firm Name t- Certified Tester r L .� t Firm Address ( Cert. Taster Na ' -ice Date �� /� �/� Gauge # (7 / Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy