2013_0703 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ' �i' X 60
PWS I.D. #
LOCATION OF SERVICE:
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.
❑
❑
Manufacturer
TYPE OF ASSEMBLY
Reduced Pressure Principle Cl Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
E�,) Q-H , Size
Model Number q0q 0 Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address ?�'� �� J (?rr q I A✓ �. -�
Gauge #
Date last accuracy tested -t (,3 / / -z—
RAJ
Certified Tester
Cert. Tester No. " Date' r /.
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
psid
Tight ❑
Leaked C]
psid
psid
C
a65
RP -_psid
Leaked ❑
Did not Open ❑
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
Firm Address ?�'� �� J (?rr q I A✓ �. -�
Gauge #
Date last accuracy tested -t (,3 / / -z—
RAJ
Certified Tester
Cert. Tester No. " Date' r /.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy