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2014_1009 (3)
C�IBCK ONE: � IRRIGATION � DOMESTIC FIBELINE BACKFI.OW PREVENTION ASSEIV�LY TEST AND MAINTENANCE REPOR? NAME OF PWS: �T OPi! ��D ��i'S��t �� �j�P�� PWS I.D. # LOCATION OF SERVICE: `�'0� ����9 The bacl�low preveation assembly detailod below has been tesud aad maiIIta�nCd as required by TNRCC reguladons aad is certified to be opczating withia acceptable paramcters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacuum Brcaker �} Double Chcck Valve ❑ Amaosphere Vacuum Breaker .�I/ Mauufactsacr Siu Model Ivumber ���f (1/ f Located At �r D11�F' �C�'E:-_'S Serial N�mmber f'1 ��0 3�� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check�alve Assembly lst Check � ;� 2nd Checl: �►(„ g�ef Valv� :d►ir Inlet Check Valve Inidal Test DC-Closed Closed Tight Opeaed at Opened at _csid �r^ Ti�t ,"1� Leal:cd o psid _nsid �� ��/ RP-_psid Leal:od ❑ Did not Opcn o Lealced O �P� and Materiais Uscd Tast After DC-Closed Closed Tight ❑ Opene�at Opeaad at _�sid Repair Ti,ht � nsid osid RP sid Tlie above is certifiod to be true. 1 . �Firm Name ��� �� Certified Testa �6�U IC� Firm Addrr.gs ��� �" ' Cert. Teste No. � Date I`T c8� � 7�g0�C� llate last accuracy tested -1 8 �� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy