2013_1105 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: IV P C J
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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
Double Check Valve
Manufacturer
n,fr'O
Model Number
Serial Number 1ZZ
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size /
Located At S C. O f r'i f ►' O �0 r6
The above is certified to be true.
.�
Firm Name Cnn ID el 45 Certified Testa %
Firm Address C1 Cat Testa No. Date S
Gauge #
Date last accuracy tested
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 Z,
2nd Check �„
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
RP -_osid
Leaked ❑
psid
_ osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight o
psid
osid
RP sid
The above is certified to be true.
.�
Firm Name Cnn ID el 45 Certified Testa %
Firm Address C1 Cat Testa No. Date S
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy