2016_1012 , ,_._ _ . , . : „ . .:
C�IECK ONE:
IRR.IGATION DOIYIESTIC FIRELINE�
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
�
NAME OF PWS: ��� �' \�
PWS I.D.#
LOCATION OF SERVICE: � � I V
The baci��low prevmtion asscmbly detailed below has beea tested aad maintained as required by TNRCC
reguladons and is cercified to be operating within acceptable parameters.
TYPE OF ASSENNiBLY
� Reduced Prtssure Principle � Pressvre Vacu�Breaker
❑ Double Check Valve o Amnosphere Vacuum Breaker
r
Maaufacturcr Siu a.
Modei Ivumber s�O O� 1'��� Located At J W c��1
Serial N�ber ( 1 �" !� `� �� `�-.Q S� �C� �C�C �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULJM BREAI�R
Doubie Check Valve Assembly �
\
lst Check 2nd Checl: Reiief Valve Air Inlet Checic Vaive�� �
Ini�al Test DC-Closed Closed Tight � t Opened at osid
���a-� � Ti¢ht�, l� Leal:ed o �� sid _osid
RP- `�`�Dsid �. �,
Lcal:ed ❑ Did not Opea O Leal;ed �
�P�
and
Materials
Used �
Test After DC-Closed Closod Tight o Optned at Opeaed at _nsid
Repair Tight � nsid osid
RP sid
The above is catifiod to be true.
Firm Name �� ��`�� �n� Certified Teste �Y�`� �� �� �-t C'�_
Firm Addrcss �� � I-�c �� �`1 � 1 l� Cert. Tester No. �p�oc�(�S�3Date I �—��—I lA
I-
�v�..�,c� � 119� 7"x�5 i3')
cg�e � � I� tJ'���,
llate last accuracy tested !- � .-.-� �j
�White- Customer's Copy Yellow - City Copy Pink-Tester's Copy