2013_0102CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C, ae l / Y l !
PWS I.D. #
LOCATION OF SERVICE. Q
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 parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer C� -jC�1--� 5
Model Number
Serial Numbers T �,
Size
Located At
X). 64C•
The above is certified to be true.
Firm Name �— sb , Certified Tester Q V' �' �`�'�
Firm Address 1-3c)!3 • 0j r r ey-6 r• Cert. Tester No. ' Date % Z
Gauge #
Date last accuracy tested
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 d
Opened at
Opened at
psid
Tight c
RP -_psid
Leaked ❑
psid
psid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
o psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name �— sb , Certified Tester Q V' �' �`�'�
Firm Address 1-3c)!3 • 0j r r ey-6 r• Cert. Tester No. ' Date % Z
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy