2013_0925CHECK ONE'.
IRRIGATION DOMESTIC FIRELINE
RACKFLOW PREVENTION ASSEMBLY TEST AND MAWTENANCE REPORT
NAME OF PASS:
PWS I.D. ,, f
LOCATION OF SERVICE: "� - fp
The baci now preveunon assembly demiled below has becu hoed and maw as required by TNRCC
reputations and is certified to be opa=g wWgn aweptable. Pte-
TYPE OF ASSEMBLY
n Reduced Pressure Principle 0 Pressure Vag Breaker
Double Chem Vain 0 Atmospbere Vacua Breatxr
l�
Manufactu ar Size
Model Number Located At
Serial Number � 7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd C beck Relic€ Valve Air Inlet Check Valve
Initial Test DC- Closed /l Ckwed Ti& at - trs-id
T.Qht Lzdmd nsid
RP- _____psid �� Did not open n Lamed
Leaked
Repairs
and
Materials
Used
Test Af= DC- Closed Closed Tilt a Opened at Opened at
Reps Tisktt 0 — asid usid
RF
Firm Name � , ! � Cerdfied TaW U V h h I I (.0 f _l (� _ —
Firm PC 7 Cat Tester No. Due
txauge f
Date last accuracy tested 1i� 3