2013_1105 (2)W
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACHnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. lage— LOCATION OF SERVICE: t 0C V I R
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
Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer ( t_ A Size
Model Number X -7
Serial Number n .�I f
SIM
The above is certified to//be true. �^
Firm Name el �J L) Certified Tester
t
Firm Address 3 0 &�O Y �✓- Cert. Tester No. Date r
Gauge # _ ZS P000
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
1st Check �, `�.
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 7
Opened at
Opened at
psid
wbTight
❑
RP— psid
Leaked O
psid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
osid
RP-----psid
The above is certified to//be true. �^
Firm Name el �J L) Certified Tester
t
Firm Address 3 0 &�O Y �✓- Cert. Tester No. Date r
Gauge # _ ZS P000
Date last accuracy tested ]
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy