2013_1024 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: i� Pr
PWS I.D. #
LOCATION OF SERVICE:
The bacLflow 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
o Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ,r_,..
Model Number — C X
Serial Number `t -f
3
Size
Located At ` - O r
The above is certified to be true.
Firm Name -U % t Certified Tester Ro 11 t
I f .,`/�`
Firm Address - 3 D3 rory xc✓ Cat. Tester No. ?�' � ' U Date /p °2 /
Gauge # -715H)00
Date last accuracy tested S 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEIIMLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check :- y
2nd Check:
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight ❑
Leaked o
psid
osid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
� sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name -U % t Certified Tester Ro 11 t
I f .,`/�`
Firm Address - 3 D3 rory xc✓ Cat. Tester No. ?�' � ' U Date /p °2 /
Gauge # -715H)00
Date last accuracy tested S 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy