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2014_0630 CHECK ONE: / IRRIGATION DOMESTIC !/ PIRELINE BACIC LOW PREVENTION ASSEMBLY MAINTENANCE REPORT NAME OF PWS: U�/ �� E 14. /7 c.e9 PWS I.D. # � .7.117/ Lc -2 / / i / LOCATION OF SERVICE: The baeldlow prevention assembly detailed below has been tested and 7nainrairted as required by TNRCC regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY g o Reduced Pressure Principle ❑ Pressure Vacuum Breaker Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer 1.1 -204 45 Size //Z Model Number 9 F � J lY 7 Located At « % cs!ct c /o 5E - ea -Fe- Q Serial Number 43 1 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BAF AICER 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 _psid P aS ? Tight ❑ Leaked a 3. psid y RP- . Opsid Leaked ❑ Did not Open a Leaked O Repairs and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at _psid Repair Tight a osid osid RP psid The above is certified to be true. Firm Name Ce2 pp-F.1 /• � Certified Tester . n a f 1 � ! Firm Address /3 © Cij al r�Cert. Tester No. d7( �rO- � ! � a Date (4 130 Gau # 7,SC�CICZ— Date last accuracy tested q/5//....3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy