2013_0703CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
r'
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The baclflow 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 W0+4
Model Number .�� 9 fn
Serial Number �q-7
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size ^
Located At A 55 en^ b
The above is certified to be true.
Firm Name )e Certified Tester - I
Firm Address l o31; n9� �'✓ Cat Tessler Noa Date
Gauge #
Date last accuracy tested I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
RP- r Sid
Leaked ❑
psid
DSid
Leaked ❑
Did not Open 12
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
pSid
Repair
Tight ❑
psid
pSid
RP sid
The above is certified to be true.
Firm Name )e Certified Tester - I
Firm Address l o31; n9� �'✓ Cat Tessler Noa Date
Gauge #
Date last accuracy tested I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy