2013_0708 (2)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ". r�00 M tdile SU � r�
PWS I.D. #
LOCATION OF SERVICE:
The back -low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable par=eters.
/9- Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number �i CA
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size i il2""
Located At ` ,fl�
The above is certified to be true.
Firm Name ,- a� I ` 1
Firm Address I -SM L Q ee6 ✓- Cert. Tester No. Date g +3
Gauge # _fig
Date last accuracy tested S
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 ❑
Opened at
Opened at
osid
ht7
Tight ❑
RP -_psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
�� sid
[!!�—
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name ,- a� I ` 1
Firm Address I -SM L Q ee6 ✓- Cert. Tester No. Date g +3
Gauge # _fig
Date last accuracy tested S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy