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2013_0906 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: 15er V1 Ge e4ep i,sp PWS I.D. # LOCATION OF SERVICE: �© L�, IE'►� ✓ The back-fiow 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 000+}s Model Number ?� 1 i. Serial Number A Z91 45 rr Size Located At 4 The above is certified to be true. Firm Name Certified Tester V �` Fins Address Cat Tester No. Date Gauge # 2A;13000 Date last accuracy tested S ( 3 White — Customer's Copy Yellow — City Copy Pink — Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1st Check 2nd Check ~' Initial Test DC- Closed Closed Tight ❑ Opened at Opened at psid Tight a Leaked ❑ -psid �ao RP -� Sid ^pSid Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at psid Repair Tight ❑ psid psid R?-----psid The above is certified to be true. Firm Name Certified Tester V �` Fins Address Cat Tester No. Date Gauge # 2A;13000 Date last accuracy tested S ( 3 White — Customer's Copy Yellow — City Copy Pink — Tester's Copy