2014_0102 (3)W.
CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF FWS:
� � N � a S601-,
FWS I.D. #
1
LOCATION OF SERVICE: C u
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer �'vaTT 5
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
}}
Firm Name D./ Certified Tester t
Firm Address �(J 5 W ra �`'� �'' Cert. Tastes No. 4f w7`. Date 2 '
?� Gauge #
Date last accuracy tested -Y ,
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 o
Opened at
Opened at
oSid
Tight ,• ❑
RP- pSid
Leaked o
psid
oSid
Leaked o
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
oSid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
}}
Firm Name D./ Certified Tester t
Firm Address �(J 5 W ra �`'� �'' Cert. Tastes No. 4f w7`. Date 2 '
?� Gauge #
Date last accuracy tested -Y ,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy