2013_0103 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: s-
PWS I.D. #
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer 10044
Model Number 9 y LX
Serial Number
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size
Located At 141y
The above is certified to be true.
Firm Name e Certified Tester
Firm Address CV } r Cent Tester No. 6e" Date
Gauge #
Date last accuracy tested Z--
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
5
Tight ❑
Leaked o
psid
_ psid
ROLE
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight o
osid
psid
RP sid
The above is certified to be true.
Firm Name e Certified Tester
Firm Address CV } r Cent Tester No. 6e" Date
Gauge #
Date last accuracy tested Z--
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy