2013_1105CHECK ONE:
IRRIGATION_ DOMESTIC FIRELINE
BACKFLOW PREV.— E-NMO-(N iEMMLY TEST AND MAINTENANCE REPORT
NAME OF PWS: t
PWS I.D.
LOCATION OF SERVICE:
The bacldlow 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
JO Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size z
�±
Model Number Q s�Q Located At S C . G r-r i er O �°-
Serial Number'"
The above is certified to be true.
Firm Name Cng3 Certified Tester
Firm Address Cent Tester No. Date
Gauge # 25S6a0
Date last accuracy tested 15 L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check ,
2nd Check �,
Initial Test
DC-CIosed
Closed Tight
Opened at
Opened at
nsid
R�
Tight )Q
RP -_ -psid
Leaked ❑
nsid
usid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
____psid
Repair
Tight ❑
,nsid
sid
RP sid
The above is certified to be true.
Firm Name Cng3 Certified Tester
Firm Address Cent Tester No. Date
Gauge # 25S6a0
Date last accuracy tested 15 L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy