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CHECK ONE:
IRRIGATION ' DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # 2
LOCATION OF SERVICE: N n VA
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
'�l41 Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer`!"`
Model Number M
Serial Number 4 rr' t
Size
Located At _
The above is certified to be true.
Firm Name Certified Testes F'J
Firm Address 13 0 Wra!S WU ✓' Cent Tester No. � � Date IL5
inGauge # .�
Date last accuracy tested rj 13
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
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
psid
a�
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked Cl
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
oSid
Opened at
oSid
`� sid
RP sid
The above is certified to be true.
Firm Name Certified Testes F'J
Firm Address 13 0 Wra!S WU ✓' Cent Tester No. � � Date IL5
inGauge # .�
Date last accuracy tested rj 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy