2013_0102CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BAC ULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 0 0
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
o Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
r� l�44g
I Ix J
Serial Number J <?p
Size
Located At
The above is certified to be true.
s
Firm Name Certified Tester
Firm Address -[I ►' Cem Tester No. �� Date
Gauge it
Date last accuracy tested L�
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
Tight C2
RP-_„psid
Leaked o
psid
^osid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
s
Firm Name Certified Tester
Firm Address -[I ►' Cem Tester No. �� Date
Gauge it
Date last accuracy tested L�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy