2013_0103CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACI{FLOW 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name Certified Tester
ZD
Firm Address 1 303 VJ rc!2@ _ Cert. Tester No. F—T Date 3 13
Gauge #j�Q
Date last accuracy tested .� 3 � 1 Z-
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
LL
Tight ❑
Leaked ❑
psid
_osid
RP- pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name Certified Tester
ZD
Firm Address 1 303 VJ rc!2@ _ Cert. Tester No. F—T Date 3 13
Gauge #j�Q
Date last accuracy tested .� 3 � 1 Z-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy