2013_1105 (5)v
CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: S�
PWS I.D. #
p� t
LOCATION OF SERVICE: �I ! e) (3 r -04,
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 0-0745
Model Number
Serial Number l
Size
Located At Frzw , 14
The above is certified to be true.
C
Firm Name n 'J Certified Tester D
Firm Address , /��/ Cert. Tester No. D Date
Gauge #
Date last accuracy tested !J
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
psid
Tight ❑
RP- _.psid
Leaked ❑
psid
,DSid
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----psid
The above is certified to be true.
C
Firm Name n 'J Certified Tester D
Firm Address , /��/ Cert. Tester No. D Date
Gauge #
Date last accuracy tested !J
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy