2013_0708W
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACK]FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Q el' (Y\, % � tt- Da! 4
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer f JA ` Size 1 �/ Z
Model Number Located At A
Serial Number
The above is certified to be trot.
Firm Name 7p ` Certified Tester Dry u i d t
Firm Address ' �,� �fQ� � _ �� C �� ,
Cat Tester No. %> �- Date
Gauge #-
Date last accuracy tested 4-ft`'
; ( i I ce..
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
Tight ❑
Leaked o
psid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Rep airs
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 trot.
Firm Name 7p ` Certified Tester Dry u i d t
Firm Address ' �,� �fQ� � _ �� C �� ,
Cat Tester No. %> �- Date
Gauge #-
Date last accuracy tested 4-ft`'
; ( i I ce..
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy