2013_1105 (3)CHECK ONE:
IRRIGATION_ DOMESTIC FIRELINE
BACKYLOW P NTION A jSSEM 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D.
LOCATION OF SERVICE: I L4 I
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.
❑ Reduced Pressure Principle
'v Double Check Valve
Manufacturer L1 S
Model Number CnM I D-1
Serial Number N -z�4
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Z`r
Located At 1 �T
The above is certified to be true.
Firm Name 4-w—
Firm Address �
LA
Gauge # Z,159 J)C) (� a
Date last accuracy tested
Catified Tester D ' t lej
Cat Tester No. 6ro Date
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 -&t t)
2nd Check 1.8
Initial Test
yo/7
DC- Closed
Tight
RP - ---psid
Closed Tight
Leaked o
Opened at
psid
Opened at
nsid
__, esid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
_ nsid
Opened at
osid
�_ nsid
RP std
The above is certified to be true.
Firm Name 4-w—
Firm Address �
LA
Gauge # Z,159 J)C) (� a
Date last accuracy tested
Catified Tester D ' t lej
Cat Tester No. 6ro Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy