2013_0906 (5)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:' T�
PWS I.D. #
LOCATION OF SERVICE: er c1t r'
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 a Atmosphere Vacuum Breaker
Manufacturer Oct *+!5 Size
Model Number 007 M 1
Serial Number A zs(,g r
2�
f/F
Located At K _ 1 � C J'
The above is certified to be true.
Firm Name r*el Certified Tester )3U
,
Firm Address 130 0raL44, r Cert. Tester No. Date Q
Gauge # 'a'5
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 Z ,
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
c,
Tight ❑
RP- psid
Leaked o
psid
osid
Leaked ❑
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight Co
Opened at
psid
Opened at
psid
nsid
RP sid
The above is certified to be true.
Firm Name r*el Certified Tester )3U
,
Firm Address 130 0raL44, r Cert. Tester No. Date Q
Gauge # 'a'5
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy