2014_1006 �
C�IECK ONE:
,
IRRIGATION �/ DOMESTIC FIRELINE
BACKFLO PREVENTION ASSEMBLY TES'T AND MAINTENANCE REpORT
NAME OF PWS: � +n ��
PWS I.D.#
LOCATION OF SERVICE: �-�oO �t�� 4��� I��
The bacl�low preveatioa asscmbly detailed below has beea tested aad maintaiaed as required by TNRCC
regulacons and is cert�ificd to bc operating withia acccptable parametets.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle 0 Pressure Vacuum Breaker
� Double Checic Valve ❑ Amaosphere Vacuum Breaker
Manufacturer ��f'C S Siu �.
Model Number �� rn � � Located At �� � �
Serial N�ber
REDUCED PRESSURE PRINCIFLE ASSEMBLY PRESSURE VACiTUM BREAI�R
Doubi�Check v alve Assembly
lst Check 2, I Znd Chec1:2� � ��f Valve :d►ir Inlet Checi�Valve
Initial Test DC-Closed Closed Tight� Opeaed at Opened at ,_osid
Ti�i ,� Lcal:ed ❑ osid _nsid
RP-_,psid
Leaked o Did not Opea o Leal:ed o
�P�
and
Materials
Used
Test After DC-Closed Closed Ti,pht o Opeaed at Opeaed at ___nsid
Rtpair Tigttt o Dsid osid
RP sid
'Ilie above is certifiod to be true.
FirmName �-�� CertifiedTes�ter � ,�C£� �I
� ��5� Date � 1
Firm Addrrss � � Cert. T�ter No.
Gauge # �
llate last accuracy tested � (�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
i