2012_1116CHECK ONE:
IRRIGATION
go
DOMESTIC
FIRELINE
BAMLOW1 PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: ~CA M (/ i�) � U
The back -Low 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
,' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number (_)
Serial Number
Size
Located At
or 0C prrerk
The above is certified to be true.
Firm Nam` ' Certified Tester
Firm Address `-,- -, fQ �1� � v;.
11 Cert. Tester No. Date
Ga e #
Date last accuracy tested ��
White — Customer's Copy 'i t Yellow — City Copy
Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
Leaked ❑
psid
oSid
R.P- __,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Nam` ' Certified Tester
Firm Address `-,- -, fQ �1� � v;.
11 Cert. Tester No. Date
Ga e #
Date last accuracy tested ��
White — Customer's Copy 'i t Yellow — City Copy
Pink — Tester's Copy