2013_0906 (4)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BAMLOW PREVENTION ASSEMBLY TEST AND tMAINTENANCE REPORT
NAME OF FWS: C� pel' 1 t 1 iaa lE? GI'\DD� 1N�`1
PWS I.D. #
LOCATION OF SERVICE: 1
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 C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer I 004e:>
Model Number M I (, f
Scrial Number A `i _ ` p -5 �
Size
Located At Q a ►�'� r.
The above is certified to be true.
Firm Name( r S
Firm Address n a, Y
Gauge # �0,5 00
Date last accuracy tested 5 xj
Certified Tester V 1
Cat Testa No -75�3 Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check •b
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
_psid
Tight ❑
Leaked ❑
psid
oSid
RP- _pSid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
pSid
RP sid
The above is certified to be true.
Firm Name( r S
Firm Address n a, Y
Gauge # �0,5 00
Date last accuracy tested 5 xj
Certified Tester V 1
Cat Testa No -75�3 Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy