2014_1009 C�IECK ONE:
IRRIGATION ✓ DOMESTIC FIRELINB
BACKFLOW PREVENTI�N ASS LY TEST AND MAINTENANCE REpOR?
NAME OF PWS: �rP��� I � I�� °tr. ��OD� U�✓�
PWS I.D.#
LOCATION OF SERVICE: I� �1�J R��!� Y
The bacl�low preveation assembly detailod below has beea tested aad maintaiaed as requirrd by 'INRCC
regulanons aad is certified to be operating withia acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaktr
� Double Chxk Valve o Atmosphere Vacuum Breaker
Manufacturer �.�.�Q TPT Size Zr/
Model Number [J�� � r � Located At ��'r C"`�
Serial N�mmbcr � ��� r
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doubie Check Valve Assembly
lst Check Z� � 2nd Checl: Z�D �ef Valve Alir Inlet Check Va1ve
1ni � Test DGClosed Closed Tight �6 Opeaed at Opeaed at nsid
r_� Tight �d Leal:cd o psid _osid
Ql� RP-_psid
Leal:ed ❑ Did not Open o L,ealced o
�P�
aad
Mataials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at _nsid
Rtpair Ti�hht � _�sid nsid
RP sid
Tlie above is cGrtified to be true.
j,� ,
Firm Name �� �� Catified Teste � �1
Firm Address ������� � � ✓ Cert.Teste No ��1� Date �d g 1�
Gauge # ���
llate last accuracy tested / S � !
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
C�ISCK ONE:
IRftIGATION_�_ DOME$TIC FIftELINE
BAC�I.OW PREVENTION ASSEIV�LY TES?AND NANCE REppRT
NAME OF PWS: C�O o 1 �'S''��
PWS I.D.# � �
LOCATION OF SERVICE: � r Y �r
The bacl�low preveation asscmbly decailed below has been tesud and maintained as required by TNRCC
regulations aad is cudfied to be operating within acccptable paramcu�s.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacu�Breaker
�!` Double Check VaIve o Amaosphere Vacuum Breal:er
Z�1
Maaufactiaer � '� Size
Modei Ivumbtr ��� � , Located At E� 5'� o� ���nn�
Serial Nu�ber t-t "C� �P��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check v alve Assembly
lst Check Z,, � ?nd Checl: 2.1 �ef Valv� :�ir Inlet Check Valve
:R
Inidal Test DC-Closed Closed Tight � Opeaed at Opeaed at ,_nsid
Ti�t �- Leal:cd ❑ osid __,nsid
Qo-�� RP-_psid �
Leal:ed � Did not Open o Leal:ed o
��
and
Materials
Used
Test ARtr DC-Closed Closed Tight 0 Opened at Opened at _�sid
Repair Tight � _�sid nsid
RP sid
'Ilie above is ccrtifiod to be true.
Firm Name��OP_I� .1 S� . CatiSed Tcsta� �� �
Firm Address I� Cert. Tester Na � Date �� �
Gauge # ��QD
llate last accuracy tested � (�
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy