2014_1006 �
C�IBCK ONE:
IRRIGATION�_ DOMESTIC FIftELINE
BAC'I�LOW PREVENTION ASSFN�LY TEST AND MAIIV'TENANCE REPORT
NAME OF PWS: �i
PWS I.D.#
LOCATION OF SERVICE: ��� �i �lt/(i'�'� �r.
The bacl�]ow preveatioa asscmbly dctailed below has been tested and maintaiaed as required bv TNRCC
reguladons and is certified to bc operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressvre Principle o Pressure Vacuum Breaktr
� Double Check Valvc o Amaosphere Vacuum Breaket
Mauufactiaer Size zl�
Model Ivumber ��( �� l Y� � Located At N � �a'�Y� �. C�
Serial N�ber � �J�� �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Check Znd Checl: Relief Valv� tir Inlet Check Valve
Iniaal Test DC•Closed Clos�d Ti;ht Opeaed at Opeaed at nsid
Ti�t � Leal:ed ❑ nsid _osid
��� RP-_psid
Leal:ed ❑ Did not Open o Lealced o
��
and
Materials
Used
Test Aft,er DC-Closed Closed Tight o ppeaed at Opeaed at _osid
Repair Tight � _osid nsid
RP sid
The above is certifiod to be truc.
Firm Name���„l�S� Catified Testa ���`� � C��
: ,
Firm Addr�ess �� T Cert Testc No. ���Date �b�� ,�
Gauge # "2'S ('��
llate last accuracy tested�� ��+
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy