400 Cowboy ; _. _ :
C�IBCK ONE:
IRRIGATION v� DOMESTIC FIRELINE
BAC'KI�7,OW PREVENTION ASSENIBLY TEST AND MAINTENANCE REPORT
�
NAME OF PWS: -pfl�'I� ,--� �� m���
PWS I.D.#
LOCATION OF SERVICE: ��� �� �
The bacl�low prcveatioa asscmbly detailed below has been tested and maintaiaed as required by TNRCC
regulauons and is cerofie�to be operating within acceptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
� Double Check Valve o Amaosphere Vacuum Breal:er
►►
Manufacturer ��- L� Size Z
Modei Number ��� Located At ��� ��"� �
s��rr�� � D"13�►�3
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSUltE VACUUM BREAKER
Doubie Check Valve Assembly
lst Check G��3 2nd Chec1: Z� Retief Valv� :d►ir Inlet Checic Valve
Ininal Test DC-Closed ' `Closed Ti�ht Opened at Opened at esid
/ Ti�i �. Leal:cd o osid _osid
al� RP-_psid
Lea� ❑ Did aot Open ❑ Leal:ed o
�P�
and
Materials
Used
Test ARer DC-Closed Closed Ti,Qht ❑ Opened at Opmed at �osid
Repair Tight ❑ �sid __osid
RP sid
The above is certified to be true.
Firm Name� I� .1�� Certified Testa �Q U � � � � I�`Y
( ��,, Q ;
Firm Addrtss � �—�`�"' "'� 1 '� �� Cert.Teste No. Date
Gauge # 2�D��
llate last accuracy tested 1 � ��
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy