2014_0102W
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS:
PWS I.D. #
LOCATION OF SERVICE
--�0i 1 'lY70yz, I :.-
a
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
PRESSURE VACUUM BREAKER
w ci �4s
Manufacturer
Model Number
AJ l
2nd Check
Serial Number
115
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size i Located At 4 ` (� 'Q f l Cej I % I lr r
The above is certified to be true.
Firm Name Q Doe �Certified Tester r
Firm Address 303 w( �WU ( Cert. Tester No. `��� ate
Gauge # ZS
Date last accuracy tested
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 o
Opened at
Opened at
oSid
Tight CK
RP- , oSid
Leaked o
psid
oSid
Leaked o
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
�� sid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name Q Doe �Certified Tester r
Firm Address 303 w( �WU ( Cert. Tester No. `��� ate
Gauge # ZS
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy