2014_1009 -
C�ISCK ONE:
IRRIGATION � DOMESTIC FIRELINE
BACI�LOW PREVENTION ASSFN�LY TEST AND MAINTENANCE REppR?
NAME OF PWS: �--��P1p e�� -�—S`,� `�-UM ,pl�-/
PWS I.D.#
LOCATION OF SERVICE: `'� �
The bacl�low preveation asscmbly detailed below has been tested and maintaiaed as required by TNRCC
reguladons aad is certified to be operating withia acceptable paramcters.
TYPE OF ASSEMBLY
❑ Reduced Pressurc Principle o Pressure Vacu�Brcaker
� Double Check Valve ❑ Amaosphere Vacuum Breaker
�O 2' '
Maaufacturer �� C(� Siu
Modei Number �`S�Q Located At �rQY1'� �� C 4: ��
s«;�rr�ba � ��3?�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check 2nd Checl: Relief Valv� :dlir Ialet Check Va1ve
Ini�al Test DGClosed Closed Ti,ght o Opened at Opeaed at _�nsid
� � Ti�i C7 Lcal:ed o nsid __�osid
(j, RP-_„psid
L.eal:od ❑ Did not Open a I,ealced ❑
�P�
and
Materials
Used
Test A,fter DC-Closed Closed Ti,pht o ppened at Opeaed at _�sid
Repair Tight o _�sid nsid
RP sid
The above is certifiod to be true.
Firm Name � p�� J--S� Catifizd Tcsta �Q U �� I� t �
t �Qp�,
Firm Address � 3� �ra� ''� Cert Tes�r No. VI vO�Io�Date I� Q I
Gauge # ���
llate last accuracy tested � g ���
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy