2014_0630 CHECK ONE:
IRRIGATION DOMESTIC ✓ FIRELINE
BACICFLOWREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
ME
NA OF PWS: CO PP 2 I ' t [� ' 5 1" nel n S-4
PWS I.D. # / /
LOCATION OF SERVICE: `� 00 o /"N 9 t t1 .
The baeldlow 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 1A. )(AA C. Size 1 1 / - 2-
Model Number Q n C` p � , N l Located At R M 4 1 ? u-� 1,-k'i i r S
Serial Number 1 4 33 /1 (O
- -- - --
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BRE-ATCER
Double Check Valve Assembly
1st Cheek 2nd Cheek Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed Closed Tight ❑ Opened at Opened at nsid
Tight ,, ❑ 3 • Cc. paid nsid
S S RP- �' nsid
Leaked ❑ Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at nsid
Repair Tight o nsid nsid
RP _nsid
The above is certified to be true. n
Firm Name C. P P e 1 S Certified Tester D EAU d t 1
`
Firm Address 1, 5 (-3� 0a 1e" --a--- Cert. Tester No. ae0.O1;63 'Date - 3O - / 4
Co T ca
Gauge # ZS BUC:k=) /
Date last accuracy tested C f / '�j / J 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CHECK ONE:
IRRIGATION DOMESTIC FIRELIN
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE
CE REPRT
NAME OF PWS: Cope � } 1 (F 1 A 1 c 1 noes, T
1 (;�QST 'J
PWS I.D.
LOCATION OF SERVICE: 4-00 rvi oGl_,4.- , !✓ t v� f—t"�
The bacltlow prevention assembly detailed below has been tested and rr.ait,r as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
PIO Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere VaFuum Breaker
Manufacturer [J--)a 4 tS Size . / �Z /
T
Model Number 41( 1 I 77 Located At g 1--/, L L r s-ta i, 01 G 6-k*-
t
Serial Number 4/ 355 f I
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREATCER
Double Cheek Valve Assembly
1st Check 2nd Check Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed Closed Tight ❑ Ownell at Opened at osid
P R P - Leaked ❑ osid osid
d S 5 RP- psid
Leaked ❑ Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used -
Test After DC- Closed Closed Tight ❑ Opened at Opened at osid
Repair Tight ❑ nsid osid
RP psid
The above is certified to be true. �j l
Firm Name ( _ � per ( —S D Certified Tester vQU 1 p 1
Firm Address ( 3 (� JFQ rl 9 e.- � � Celt Tester No. ef /5 Date W-3C6 /
Gauge # Z
Date last accuracy tested 4/5/43
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AN N'
D MAINTENANCE REPORT
NAME OF PWS: �Pf'ei1 1 / � 1 N de scl�I'10c71 /
PWS I.D. #
LOCATION OF SERVICE: 960 /nock; • Z/1
The bacl. 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 0 Pressure Vacuum Breaker
o Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer 44 Size / /Z (�
Model Number O� r) - Located At Z5 00 ! R LL Cu 5 5 do 1 e i•S
Serial Number 4. d
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
1st Check 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight 0 Opened at Opened at osid
Tight Z Leaked o z • psid osid
RP- L ` psid
Leaked O Did not Open 0 Leaked O
Reps
and
Materials
Used
Test After DC- Closed Closed Tight 0 Opened at Opened at osid
Repair Tight o osid osid
RP psid
The above is certified to be true.
)
Firm Name `moo P p � 5 E Certified Certified Tester
� a U i d 631
Firm Address / 3o3 w 1 � / � �g /�' L-+ Cert. Tester Noit/C0067 Date ( c/ 56 4
Gauge #
Date last accuracy tested Q f �6//5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy