2014_0102CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACTOFLOW 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 ' S Size �l
Model Number Located At '' e Z -z-
Serial Number / Z 16 �) 1 -
Ad -s - C /<
The above is certified to be true. R,
p , �L:c I Firm Names ' II �D Certified Tester
Firm Address 1 Q3 bra y tV Cert. Tester No. �(67 Jb Date Z /�
Gauge # z ��' 1B
lu �
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
D C1
Leaked ❑
psid
osid
1
`7
sid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
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. R,
p , �L:c I Firm Names ' II �D Certified Tester
Firm Address 1 Q3 bra y tV Cert. Tester No. �(67 Jb Date Z /�
Gauge # z ��' 1B
lu �
Date last accuracy tested �' l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy