2014_1009 (2) C�iECK ONE: �
IRRIGATION ✓ DOMESTIC FIRELINE
BAC'I�LOVy,�REVENTION ASSEh�LY TEST AND MAINTENANCE REPORT
/ t (�' _ ),,� ,
NAME OF PWS: `'"d I�P�� ���� `�-o►'��I�-"Y
PWS I.D.#
LOCATION OF SER`✓ICE: �� � �
T'he bacl�low preveation asscmbly detaile� below has been tested and maintaiaed as require3 by TNRCC
regularions and is certified to bc operating withia acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principlc ❑ Pressure Vacuum Breaker
� Double Check Valvc o Amiosphere Vacuum Breaker
►►
Maaufact�er ���C� Size �
Modei Ivumber ��� Located At �rA� �E'S
Seria!Nimnber r ' ����
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VAC[7UM BREAKER
Double Check Valve Assembly
lst Check 2 ► � 2nd Checl: �� Relief valv� Flir Ialet Check Valve
Iaival Test DGClosed Clos�d Ti�ht � Opeaed at Opened at osid
Ti�t ,� Leal:cd ❑ nsid _osid
��C� RP-_�sid
Leal:ed o Did aot Open o I,ealced o
�P�
and
Materials
Used
Test After DC-Closed Closod Tight o Opened at Opeaed at __osid
Repair Tight � �sid osid
RP sid
The above is ' ed to be true.
,
Firm Name Certified Tasta 1-� (.� 1 � 1
� �� �J ��Date /a /7
Firm Addross 3 Cat Tes�er No.
Gauge # ���
llate last accuracy tested / g �
White-Customer's Copy Yellow - City Copy Pink-Tester's Copy