2013_0708CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACI FLOW(( PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: A CAtY'\ t n I S +(C-
PWS I.D. #
LOCATION OF SERVICE: ) K A
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.
❑ Reduced Pressure Principle
❑
Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At l)r oiler 4
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested -Z,
n ,
Certified Tester olu
Cert. Taster No. ('ObOeP 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: r, , .
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
oSid
RP -_oSid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested -Z,
n ,
Certified Tester olu
Cert. Taster No. ('ObOeP Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy