2013_1024 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C100all m i I
�
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PWS I.D. #
LOCATION OF SERVICE: n In" t
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ccrtified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �NlMs
Model Number r m M I �A-
Serial Number 5 -7 �n2
Size
Located At W( C K- ;U Vyy, '.
S F a4-
The above is certified to be true.
Firm Namcojcv--�koll --L-sD certified Test. '7--) o u t. iQ
No. M0158_ Date
FirmAddress �,��L�Fnr)Ql i Cert Tesw 6e
Gauge # , 36 9on n
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
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Dsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Namcojcv--�koll --L-sD certified Test. '7--) o u t. iQ
No. M0158_ Date
FirmAddress �,��L�Fnr)Ql i Cert Tesw 6e
Gauge # , 36 9on n
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy