2015_0706 (2) g
C�IBCK ONE:
�
IRRIGATION DOMESTIC � FIRELINE
� BAC'!�'I�OW REVENTI
,.P ON AS�EMBLY T AND MAINTENANG'E REppRT
NAME OF tWS: ���1�� � o� 1 i G1'A1� � �C�l �s'�l
PWS I.D. #
LOCATION OF SERVICE: Q� ��� ���"' /'�
The bacl�low preveatioa asscmbly detailod below has beea tested and maintaiaed as required by TNRCC
reguladons and is ccdfied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�y � Reduced Press�e Principle ❑ Pressure Vacuum Breaker
� ❑ Donble Check Valvc o Atmosphere Vacuum Breaker
Maaufacturer (,c/4f1F".� Size /�Z
Model Numbcr _ /0 I /� � � Located At � �-�'
Serial N�ber `7`����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACLTUM BREAI�R
Doubl�Check v alve Assembly
lst Check 2nd Checi: Relief Valve :�ir Inlet Check Valve
Iniaal Test DC-Closed Closed Tight ❑ Opeaed at Opeaed at _esid
� Ti � Leal:ed ❑ �� sid _�osid
a RP- �� sid
�
�� � Did not Opea o I,eal:ed o
�P�
and
Mataiais
Used
Test After �C-Closed Closed Tight 0 Opencd at Opeaed at _osid
Repair Tig�c a __�Dsid _osid
RP sid
'Ihe above is certifiod to be true.
� ��I � ,
Firm Name .1 �:�J Ce�tifiod Testa �� �I �
, Q
Firm Addras,s � 1� Cat Tester NaL� Dace � rv
� Gauge # Z�J Q(�
llate last accuracy tested � � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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