2013_0905c
CHECK ONE: 131
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: IJ I VG'
The back-flow 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
X, Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �- eL >�o Size t ��7,
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address L - D
1
Gauge # C-I R00c)
Date last accuracy tested j9 5 (3
certified rester U t✓
Cert. Tester No. Date 5 (1 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve j
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
RP -_osid
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address L - D
1
Gauge # C-I R00c)
Date last accuracy tested j9 5 (3
certified rester U t✓
Cert. Tester No. Date 5 (1 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy