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2013_0906_RPZCIIECK ONE: IRRIGATION x DOMESTIC FIRELINE �-'� BACTCFI.OSW PREVENTION ASSEA�LY TEST AND CE REPORT NAME OF PWS: `l � �[� � � "� � !� nr► {� PWS I.D. # LOCATION OF SERVICE: yyi� l .n� i� �n�! The bacldlow prevention assembly detailed below has bees tested and maintained gg required by TNRCC regulations sad is cc a5ed to be operatiag within acceptable parameters. ¢C! Reduced Pressure Principle ❑ Double Check Valve Maaufacaaer �e�F!'� Model Number ��D Serial Number � i� %�� 9 TYPE OF ASSEMBLY ❑ Pressure Vacuimm Breaker ❑ Atmosphere Vaeuum Breaker �r Size Z Located At S � � � SOCS-�'1� -- The above is certified to be true. Firm Name �PPe� 1 TSD Certified Tester ��(�,-,����G2. i � �-7 Firm Address l � O 3 W r� � � + r Cent. Tester No. CXU- L�V'�Sg Date Gauge Ik ZS�} O ©� �� Date last accuracy tested � S 1 3 White - Customer's copy Yeuow -city copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSE2�IBLY PRESSURE VACUUM BRF'sT�'R Double Check Valve Assembly 1st Checlt Z, Z Sad Checl: Z. ( Relief Valve Air Inlet Chec3c Valve Initial Test DC- Closed Closed Tight � Opened at Opined at osid A Ti�L T�Y RP- osid Leaked O n_ rid osid Leaked ❑ Did not Opm ❑ Leaked O �P� and Materials Used Test After DC- Closed Closed Tight o Opined at Opined at osid Repair Tight o osid osid RP rid The above is certified to be true. Firm Name �PPe� 1 TSD Certified Tester ��(�,-,����G2. i � �-7 Firm Address l � O 3 W r� � � + r Cent. Tester No. CXU- L�V'�Sg Date Gauge Ik ZS�} O ©� �� Date last accuracy tested � S 1 3 White - Customer's copy Yeuow -city copy Pink - Tester's Copy