2013_1024 (4)CIIECK ONE:
IRRIGATION
NAME OF PWS:
PWS I.D. #
DOMESTIC
FIRELINE
'PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
-00 PO iY1► ad e r✓,t�oo (� o rt
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
Reduced Pressure Principle D Pressure Vacuum Breaker
Double Check Valve Atmosphere Vacuum Breaker
a ks Size Z.
Located At
The above is certified to be true.
Firm Na -b e(f —S
Nam Certified Tester
Firm Address (� 03 �t� Cem Tester No.
Gauge #
Date last accuracy tested 5 j 3
-1
F1 � U a`�
te.�D7J Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check: 1, �
2nd Check: f,
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 0
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
osid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
�� sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Na -b e(f —S
Nam Certified Tester
Firm Address (� 03 �t� Cem Tester No.
Gauge #
Date last accuracy tested 5 j 3
-1
F1 � U a`�
te.�D7J Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy