2013_0906CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
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
F Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer PP— V) C Size
Model Number 5r() Located At V�1 n er
Serial Number ' 054Z5
The above is certified to be true. l
Firm Name l„ sc t�tJ F 1 S L: Certified Tester i —)n u i A
Firm Address Cert. Tester No. Date Q 3
Gauge #
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: _., , -i
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
psid
oSid
A 5 -'
RP -_psid
A
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
t?Sid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true. l
Firm Name l„ sc t�tJ F 1 S L: Certified Tester i —)n u i A
Firm Address Cert. Tester No. Date Q 3
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy