2014_0715 , r.. > .. ,
CHECK ONE:
IRRIGATION DOMESTIC Y FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT `
NAME OF PWS: CITY OF CORRELL
PWS I.D. #
LOCATION OF SERVICE: 2 --1 - 5 0 N ('74 .l c; CV
The bacldlow prevention assembly detailed below has been tested and rna;r,ra;ned as required by TNRCC
n¢ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuuxn Breaker
Double Check Valve Atmosphere Vacuum Breaker
Manufacturer A Size 1"
Model Number l _ F 00 7 M J Ci T Located At et'F. ✓ / iejc5 -
Serial Number d C_o t-
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRFAICER
Double Cheek Valve Assembly
1st Check 1 2nd Check Relief Valve Air Inlet Cheek Valve
Initial Test (DC- Close4 I • S / osed Tim V Opened at Opened at nsid
t � pp Tight [� Leaked 0 nsid _p sid
) PI S `.Jt RP- nsid
Leaked o Did not Open o Leaked
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at nsid
Repair Tight nsid nsid
RP psid
The above is certified to be true.
Firm Name PN.1 S�� f )F1C lC /iv r Certified Tester C )+(- V E" rTh 131
Firm Address PC") P Cert. Tester No. t�P - Date 7- / - / '{
t --Cf Li) -s x ; � rE ;"Tx 750-a4
Gauge # CS
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy