2013_0103CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
1 �!
NAME OF PWS: 'r f
PI
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 o Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number %`� . Located At
Serial Number
The above is certified to be true.
Firm Name l T Certified Testes
i
Firm Address' �rn r Cent. Tester No.� Date 3 3
Gauge # 7-5 -1
Date Iast accuracy tested b 3
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
�R�JG,
Tighe ❑
tj
RP -,psid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leak=ed ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name l T Certified Testes
i
Firm Address' �rn r Cent. Tester No.� Date 3 3
Gauge # 7-5 -1
Date Iast accuracy tested b 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy