2012_0905CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
,-117
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 ❑ Atmosphere Vacuum Breaker
Manufacturer Size��
Model Number —�t— Located At ��.:Z�l f-razter
Serial Number % X
The above is certified to be true.
Firm Name Certified Tester L f) I l J
Firm Address Cent. Tester No.' Date
Gauge #
Date last accuracy tested ' '7,
White - Customer's Copy Yellow t City Co !` +ink- Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check �, q
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked O
psid
osid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked a
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester L f) I l J
Firm Address Cent. Tester No.' Date
Gauge #
Date last accuracy tested ' '7,
White - Customer's Copy Yellow t City Co !` +ink- Testers Copy