2014_1006 (2) C�IBCK ONE:
IRRIGATION /� DOMESTIC FIRELINE
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �Q}�b� WfJ� �f �I�— �'C'rv'I�C�Y
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PWS I.D.#
LOCATION OF SERVICE: � �`�"J YY� i r1 vc�r� ��i� _
T3e bacl�low pnweatioa asscmbly detailed below has bxa teste� aad maintaiaed as required by TNRCC
regularions and is certified to be operating within acceptabie parametas.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle � Pressure Vacuum Breaker
�C Double Check Valve o Amaosphere Vacuum Breal:er
�r►
Maaufacttaer � S Sizc
Model lvumber �� ��� Located At N. �W 1�1 �. 1,,� CN�c��
s«;�rr�� 2� 13�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check Valve Assembly
lst Check I� � 2nd Checl: 2.,0 Relief Valve Air Inlet Check Valve
Inival Test DC-Closed Closed Tight � Opeae�at Opened at _nsid
Ti�ht �3 Leal:ed o nsid __„nsid
��� RP-_psid
Leal:ed � Did not Open o I,cal:ed o
Repairs
and
Materials
Used
Test After DC-Closed Closed Ti,ght ❑ Opeaed at Opcaed at __nsid
Repair Tight ❑ _nsid __nsid
R.P sid
'Ibe above is cerrified to be true.
�- ` r� �
Firm Name I l �--5 Catified Testa � U, ` t(.� '
Firm Addrcss ��J� � Cat Teste No.��UU�oyI�D� D (o �`t'
Gauge � �.,t�(j(�
llate last accuracy tested � C`�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy