2015_0706 (3) �,
C�iBCK ONE:
IRRIGATION DOMESTIC FIRELINE
m�
BACI�LOW PREVENTION ASSEN�LY TEST AND MAINTENANCE REPORT �.,
NAIv�OF PWS: � �
PWS I.D. #
LOCATION OF SERVICE: � '
The bacl�low preveation assembly detailed below has ban tested and maintained as nquire� b�, 'TNRCC
regulanons and is cudfied to be operating within acceptable paramcters.
/' TYPE OF ASSEMBLY
,w Q/ Reduced Pressure Principle � Pressure Vacuimm Breaker
❑ Double Check VaIve ❑ Amiosphere Vacuum Breal:tr
Maaufact�ez Siu J ��7,
Model Number ��' � � Located At .��7 '�12�� .� �a�
Serial N�ber �13.'�i�(a�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACU[,TM gREAI�R
Double Check Valve Assembly x� �
lst Check 2nd Cbeci: R�iief Va1v� Air Inlet Check Valve
Ini�al Test T C�-Closed � L le�al.c�.d Ti�t o �eaed at Opened at __esid
�� L psid _�osid
RP-�.,Q.psid
�a�5 I,�:� a �a noc op� o r..�:�a a
��
�a
Materials
Used
Test After DC-Closed Closed Tight o pp��at pp��at ___�sid
Rtpair Tight a _�5id _,_,nsid
RP sid
The above is certified to be true.
Firm Name `"�S Catifiod Tester ��=��_
Firm Address � �-
� Cat T�No. Date (v
��� Gauge # ��'�"j��'�
��,,_
llate last accuracy tested $ /
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
I