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2012_1116 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACTtFLOW PREVENTION ASSEMBLY TEST AND MAUgTENANCE REPORT NAME OF PWS: /n !' 0 < , A e, clem e-y-l-, - A- PWS, I.D. # LOCATION OF SERVICE: )24 The back-Dow 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 o Pressure Vacuum Breaker Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer kF -- -i144 e- Size Model Number C1 C Y � Serial Number N5 Located At D ©�� The above is certified to be true. Firm Name) 1 ! T S ,� Certified Tester Firm Address ram Cert. Tester No. N Date Gauge # Date last accuracy tested 9 White - Customer °s Copy ° / f 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 o Opened at Opened at psid Tight ❑ Leaked ❑ psid psid RP- psid Leaked ❑ Did not Open 0 Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at psid Repair Tight o psid psid RP sid The above is certified to be true. Firm Name) 1 ! T S ,� Certified Tester Firm Address ram Cert. Tester No. N Date Gauge # Date last accuracy tested 9 White - Customer °s Copy ° / f Yellow - City Copy Pink Tester's Copy