2013_071210,
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 11 Pell ...�. - -J D 1_`+ -T 41471(,
PWS I.D. #
LOCATION OF SERVICE: 1 '�
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 qno
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size i f Z-
Located At " U 4 la I C i
The above is certified to be true.
Firm Name I I -.L- Certified Tester
Firm Address ,503 (J)fOLM 18LI
V- Cert. Tester No.
Gauge #
Date last accuracy tested 3 2---
IM�•. ��
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
L
Tight ❑
RP -_psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name I I -.L- Certified Tester
Firm Address ,503 (J)fOLM 18LI
V- Cert. Tester No.
Gauge #
Date last accuracy tested 3 2---
IM�•. ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy