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Verizon-LR 990322CiIECK ONE: IRRIGATION DOMESTIC FIRELINE ~ BACKFLOW PREVENTION ASSF2VIBLY TEST AND MAINTENANCE RI!iPORT NAME OF PW$: PWS I.D. # LOCAYION OF SERVICE: G '~ '~5"0 ~,~,o~"V- P~ ! The backflow prevention ass~nbly detail~ below has b~ ~ and maintain~ as r~quired by. TNRCC rcgulatious and is certified to bc operating within acceptable parameters. TYPE OF ASSElV[BLY ~ Redu~ Pressure Principle ~ Pressure Vacuum Brcal~ 'i~' Doubtc Check Valve ~ Atmosphere Vacuum Brcak~ d REDUCED PRESSURE PRINCIPLE ASSEI~BLY PRESSURE VACUUM BREAK]~R Double Check Valve Assembly 1st Check [ 2ual Check Relief' Valve Air Inlet Check Valve Initial Test DC-Closed Closed Tight g Opcucd at Opened at psid Tight l~ Leaked r~ .psid psid RP-.3, ~ psid ~, ~- I.~aked r~ Did not Open m L~aked !and Materials Used Test ~ DC-Closed Closed Tight ~ Op~ned at Op~ned at psid R~air Tight r~ psid psid RP psid Thc above is c~rtified to b~ true. Gauge # 20 qct Y I Date l~st accuracy tested ]-7 - ~/c] White - Customer's Copy Yellow - City Copy Pink - Tester's Copy C~IECK ONE: IRRIGATION DOMESTIC FIRELINE / BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PW$ I.D. # Thc backfflow prevention assembly detailed below has been ~ and maintained as r~luired by. TNR. CC r~.m~laIions and is certified to bc operating vlrjthin acceptable pa~amet~:rs. TYPE OF ASSEMBLY [] R~uc.~d Pressur~ Principle [] Pressure Vacuum Breal~ ~;~ Double Ch~.~k Valve [] Aunosphere Vacuum Break~ REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAK]ER Double Check V~lve Assembly 1st Check [ 2nd Check Relief Valve Air Inlet Check Valve lmrial Test DC-Closed Closed Tight ~t, Opened at Opened at psid Tight :1~ Leaked o psid psid R/F- 2, ~ vsid 3, (a ~ 0 Did not Open 0 Leaked Materials Used Test After DC-Clos~l Closed Tight o Opened at Opened at psid Repair Tight o psid psid RP psid The above is certified to be true. Gauge # ,20 lq ~'~ Date last accuracy tested I - '7- White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CHECK ONE: / IRRIGATION X// DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND ~NANCE REPORT NAME OF PWS: PWS I.D. # The baedcflow prewentio~ assembly det~led below has been tested and m~inta~ed as required by. TNRCC re.mflafiom and is certified to be operating whhin acceptable param~. TYPE OF ASSEMBLY [] P.~du~ Pressure Principle ~ Pressure Vacuum Br~,k~ ~ Doubl~ Ch~ck Valve r~ Atmospher~ Vacuum Bre 'ak~r Manufacturer ~)~ Siz~ ~l" Mod~iNumber OO~ DO/ Locat~iAt 5b*~L- '~i,~.. ~¢x-4- ~o ~; ~- S~al ~u~b~r ~'/2- ~' REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUI~ BRE.AX]gR Double Check Valve Assembly 1st Check I 2nd Check Relief Valve Air Inlet Check Valve Initial Teat DC-Closed Closed Tio~ht ~' Opened at Opened at psid Tight ~ Leaked ~ psid psid Leaked a Did not Open r~ Leakezi and Mat~als Used T~ Afb:r DC.Closed Closed Tight ~ Opened at Op~n~ at psid Repair Tight [] psid psid RP psid The above is c, enifiM to b~ true. FirmAd&~ ~t. [ {Iud. ~'~?~ C=t.T~$t~rNo.~/,~'o~,~--c'~s' Dat~ aauge # ~ Date last accuracy tested !- 7- 9 9 White - Customer's Copy Yenow - City Copy Pink - Tester's Copy CtlI~CK ONE: IRRIGATION DOMESTIC FIREL!NE ,, / BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PW$: PWS I.D. # LOCATION OF SERVICE: ~"r~~' 7~0 Co~i-~L~ ~/~Lk The ba~fflow pr~vmtion assembly detail~l below has b~m ~ and maintained as requital by. TNR. CC mg~latiom and is c~ifi~ to 1~ op~'ating within acc~table param~'s. TYPE OF ASSEMBLY r~ R~uc~ Pr~ssur~ Principle D Pms~ Vacumn Bmak~ ~ Double Ch~ck Valve c~ Armosph~r~ Vacmtm Bm 'alit Mod~lN'umb~' /~i06 O,C, Locat~dAt ~O/r ~uo,..~-L Yt~/5 ~r REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI(~R Double Check Valve Azsembly l~t Check I 2ad Check Relief Valve Air Inlet Check Valve Initial T~st DC-Clos~i Clos~ Tight ~k Ol~ at Opm~ at paid Tight J~ Leak~l.~ D paid paid RP- ~, O mid Le~d m Did not Opm Matm'ials Used T~st At~ DC-Cloa~ Clo$~ Tight ca Opm~ at Opm~ at psid P,~air Tight cl paid paid RP paid The above ia ccrtifi~cl to b~ true. Gauge # ~ff~ Date last accuracy tested [,-- White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CilECK ONE: / IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PW$: PW$ I.D. # The backflow prevention assembly detailed below has been testecl and maintained as required by. TNRCC r%~darions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ~ Rm:luc.~ Pressm'e Principle m Pr:s~ Vacuum Break~ ~ Double Ch~ck Valve [] Atmosphm'e Vacuum Br~ 'ak~ Manufacturm'/'~e'~}e~ S= ~" ~,~'~mb~ /3~q. S' 50C ii ~^~ ), ,~ /o~6 L'd¢ ~ ~ /24 qf~l~32, g5.~ 5'ezu/c¢ Ld, Serial Number REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULq~ BREAKER Double Check Valve Assembly 1st Check I 2nd Check Relief Valve .Mr Inlet Check Valve Initial Test DC-Closed Closed Tight lg, Oiled at Opened at psid Tight ~ Leaked o psid psid Rff- ~'~ psid ,~. ~' l.~-.aked m Did not Open and Materials Us~ Test After DC-Closed Closed Tight m Opened at Opened at psid Repair Tight m psid .psid RP psid The above is certified to be lrue. FirmNam~ ~c~',e,~ /z~,~/.dc CerfifiedTester 5', {5,(-~ FirmAddmas ~t [. ,~a~?/~- Cerc Tester No. {/iY'-°¢'5:f~f' Date Gauge # Date last accuracy tested / ~ ~ '~ q~ White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CtIECK ONE: / IRRIGATION DOMESTIC V FIRELINE BACKFLOW PREVENTION ASSF..M~LY TEST AND MAINTENANCE RI~PORT NAME OF PWS: PW$ I.D. # The backfflow prevention assembly detailed below has been tested and maintained as required by. TN'RCC re.~tlations and is ca'dried to be operating within acceptable par-ametek. TYPE OF ASSEMBLY r, Reduced Pressure Principle = Pressure Vaanan Breaker ~ Double Check Valve [] Atmosphere Vacuum Bre 'aker Manufacturer (J,f~r-'~ Size S alNumber $2.90q REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAi~R Double Check Valve Assembly l st Check ] 2nd Check Relief Valve .adr Inlet Check Valve Initial Test DC-Closed Closed Tight ~ Opened at Opened at paid Tight I~ Leaked r~ paid paid Rig- ,,~'3 psid Leaked r~ Did not Open r~ Leaked [] and Materials Used i Test AP~ DC-Closed Closed Tight ~ Opened at Opened at psid Repair Tight c2 psid paid R.P psid The above is c.e~tified to be true. FirmNam~ /:k_ ~to ,,,' /l~o/'~n,,,'~t'c-' CmifiedTest~r 5 Gauge # 20'~ ~) Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CtIECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENAN~ REPORT NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: ~ ~'~ The bac. k~ow prevention assembly detailed below has bc~m ~ and m2intzin~xi as r~quir~d by. TNR. CC r%m~latioms and is c~rtified to be operating wi~hl, acc~table param~'s. TYPE OF ASSEMBLY m R~uc~ Pressm~ Principle r~ Pressure Vacuum Break~ fig Double Cbeck Valve [] Atmosphere Vacuum Br~ 'ak~r Manufacturer Model Number s=i N,,,-b= REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly lsr Check I 2nd Check Relief Valve Air Inlet Check Valve !Inkial Test DC-Closed Closed Tight ~, Opted at Op~ned at psid ~l~ Leaked cl ,psid psid Tight. RP- /' ~'psid }, 7 L~aked m Did not Open and Martials T~t Afire- DC-Clos~I Closed Tight m 0p~n~l at 0p~ned at psid R~air Tight I:I psid psid RP psid The above is ca'tiffed to be true. ) Gau~e # Date !_-.~t accuracy tested J -- '~ ~ White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy CtlECK ONE: / IRRIGATION DOMESTIC / FIHELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTE~C~ REPORT NAME OF PW$: PW$ I.D. # The bacldlow prevention assembly detailed below has been teatsd and maintained as rr4Mred by. TNRCC r%,ulafiom and is ca'tiffed to be op~rathag within acceptable parameters. TYPE OF ASSEMBLY ~ Reduc~l Pressur~ Principle ~. Pressur~ Vacuum Brraker ~ Double Ch~:k Valve [] Atmospher~ Vacuum Break~ ModetNumber O0~7 /fl / LocatedAt ~o~£ ~,'c/e, /iT lCuoy s~ial ~mb=- e,,, 2.'7 / ::Z. 5 ~/~c Ed. REDUCED PRESSURE PRINCIPLE ASSEI~IBLY PRESSURE VACIIUM BREAKER Double Check Valve Assembly 1st Check [ 2nd Check Relief Valve Air Inlet Check Valve Initial Teat DC-Closed Closed Tight ~ Opened at Opened at psid Tizht ~i. Leaked ~ ~sid psid Leaked I2 Did not Open ~2 l.~..,aked ~ Mata:rials Us:d Test Af~ DC-Closed Closed Tight r~ Opened at Opened at psid Ru-'pair Tight ~ psid psid RP psid The above is eartifled to be tn~. t.,/c'o.,.o ~, Date !ast accuracy tested j--~ "~ White - Customer's Copy Yellow - City Copy Pink - Tester's Copy