2013_0711CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: aCA
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
r
Manufacturer � K) � k; �S Size �?
Model Number Located At
Serial Number 1
Test Afar DC- Closed Closed Tight o Opened at Opened at psid
Repair Tight Sid oSid
RP sid
The above is certified to be true.
1
Firm Name Certified Tester , G
Firm Address 2' ~'"7 Y' Cert. Tester No. 5f Date
in Gauge #
Date last accuracy tested 3 j 7i
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEIIMLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight CO
Opened at
Opened at
Sid
,mot,
OL
Tight ❑ �..
RP -_� psid
Leaked ❑
Q psid
osid
Leaked ❑
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test Afar DC- Closed Closed Tight o Opened at Opened at psid
Repair Tight Sid oSid
RP sid
The above is certified to be true.
1
Firm Name Certified Tester , G
Firm Address 2' ~'"7 Y' Cert. Tester No. 5f Date
in Gauge #
Date last accuracy tested 3 j 7i
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy