2013_0621 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE -V
BACIs'T`LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME S:
T
LOCATION OF SER`IICE: �d S• Qoar-t
i�ll�- ha�kll���, �,r���ilti�,n a���lllhly� detailzd l)tic��y fl,l: htetl �� >acl at�d m:lint�ulled as required by TCEQ
r�;?ll�tt?it 11 Mld IS CCIIIII,:d to he op still`,_' \t Illilil ill•.'tCrs.
E Reduced Pressure l�lrmciple
w Double Check Valve
Manufacture.
Model'vumber
Se.ial Number Co ca = + 3v cr
TYPE OF ASSEN2131-Y
- Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
�«
Site
Located At ljov T `
L")'ti ; j a C
The above ' certified to be true. /-e
Firm Name & r O ,J -c-
Firm Addr= Psz 6e r :2 S -7
tit r. xC vt cc ri -,-
Gauge #
Date last accuracy tested
Certified Tester i W� K e-,-'
Cert. Tester No. 4' 4n q` / c2 5- Date 1/6/cpp/h 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
-
1
!�
�
1 st Check
tad Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
i
IBC- Closed
T12ht �
R - vsid
Leaked
Closed Tight W
Leaked �+
Opened at
nsid
Opened at
nsid
Did not Open t?
nsid
Leaked
Repairs
and
:'1�fateriaLs
Used
Test ARer �
Repair
I
DC- Closed �
Tight C
R,p Sid
Closed Tight tC
Opened at
nsid
Opened at
nsid
nsid
The above ' certified to be true. /-e
Firm Name & r O ,J -c-
Firm Addr= Psz 6e r :2 S -7
tit r. xC vt cc ri -,-
Gauge #
Date last accuracy tested
Certified Tester i W� K e-,-'
Cert. Tester No. 4' 4n q` / c2 5- Date 1/6/cpp/h 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy