2013_0708CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
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
C Reduced Pressure Principle o Pressure Vacuum Breaker
12 Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer CS Size
Model Number Z Located At i Serial Number ra'2
The above is certified to be true.
Firm Name ( L 5'd) Certified Tester�aL' C'! i-►
Firm Address !? ✓ Cent Tester No. Date 1 Q
Gauge # 7r^._ r-- '
Date last accuracy tested 3
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 0
Opened at
Opened at
psid
,3�7�7
Tight
RP -_ psid
Leaked o
psid
psid
Leaked ❑
Did not Open o
Leaked 0
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
psid
Repair
Tight o
psid
psid
RP sid
The above is certified to be true.
Firm Name ( L 5'd) Certified Tester�aL' C'! i-►
Firm Address !? ✓ Cent Tester No. Date 1 Q
Gauge # 7r^._ r-- '
Date last accuracy tested 3
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy