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2013_0906 (6)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: �._. p e l 1 ! t � Jle J c� ©o� �'S� ��'s �� i E'.tJ PWS I.D. # LOCATION OF SERVICE: f U P1q' 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 ASS; ❑ Reduced Pressure Principle ❑ C Double Check Valve C Manufacturer �--eYD C6 Size Model Number d Located At Serial Number 4 t) q -,c —7 -7 EMBLY Pressure Vacuum Breaker Atmosphere Vacuum Breaker 7, 0 The above is certified to be true. Firm Name��pel 1 �- certified Tester Firm Address �� w�`Q� Cent. Tester No. D Cocol5p� Dateq (O 13 Gauge Date last accuracy tested 13 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 osid Tight ❑ Leaked ❑ psid osid RP- _psid Leaked ❑ Did not Open o Leaked o Reps and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at osid Repair Tight o osid osid RP sid The above is certified to be true. Firm Name��pel 1 �- certified Tester Firm Address �� w�`Q� Cent. Tester No. D Cocol5p� Dateq (O 13 Gauge Date last accuracy tested 13 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy