2013_0906 (3)C�
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: (/ I' C-P . E Q'fL —_ Q,
PWS I.D. #
LOCATION OF SERVICE: (er-
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
)ZE Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer IMP Size Z �
Model Number O `� �� Located At �--
Serial Number H 0 ( q C-i
The above is certified to be true.
Firm Name 0 v e { 1� Certified Tester 7. 0 0 I �l
Firm Address -2)0S W ( a �1�C -'' Cent. Tester No.
Gauge # Z68coO
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 :? . °
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
RP —_psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name 0 v e { 1� Certified Tester 7. 0 0 I �l
Firm Address -2)0S W ( a �1�C -'' Cent. Tester No.
Gauge # Z68coO
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy