2013_0708CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: ` 0
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
Reduced Pressure Principle
Double Check Valve
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Model Number 0' '1 Located At
Serial Number �' 1
The above is certified to be true.
Firm Name _ Certified Tester 4 Q;
Firm Address ` ; v Cert. Taster No. Date
Gauge #
Date last accuracy tested 3 17
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 ❑
RP -_ Dsid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name _ Certified Tester 4 Q;
Firm Address ` ; v Cert. Taster No. Date
Gauge #
Date last accuracy tested 3 17
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy