2013_0708 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: t.e
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number t �1 )'I 5
Serial Number "47
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size)
Located At
The above is cerdfied be true.
r
Firm Addrew M lPdi r,- Ceit Tester No.
Gauge # )00
Date last accuracy tested 'S
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 ❑
Leaked ❑
psid
oSid
RP- pSid
Leaked ❑
Did not Open ❑
Leak=ed o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_^ sid
Repair
Tight ❑
psid
oSid
RP sid
The above is cerdfied be true.
r
Firm Addrew M lPdi r,- Ceit Tester No.
Gauge # )00
Date last accuracy tested 'S
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy