MacPlaza 1 City-LR 961120 (2)CtlECK ONE:
IRRIGATION
DOMESTIC FIRI~LINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTE~ REPORT
NAM~ OF PWS: ~
PWS I.D. #
LOCATION OF SERVICE:
The bacldlow prevention assembly dezailed below h,~ been tested and m,i.tsi,ed as requimt by. TNRCC
re_afl. OhS and is c~'tified to bc operating w{thin acceptable pa~...e~rs.
Manufacturer
Model N-tuber
Serial Number
Reduced Pressure Principle
Double Check Valve
:, .- ..~ .:~' 7
S~
TYPE OF ASSEMBLY
Pressure Vacm~ Br~ker
Atmosphere Vacuum Breaker
Located At ~--/)~-~7"/..~'~F 7",0.,~'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check V~lve Assembly
1st Check [ 2nd Check l~[ief Valve Air Inlet Check Valve
Initial Test DC-Clos~ ~Closed Ti~tt ~ Opened at Opened at psid
Tight lo/ Leaked ~ psid psid
P.P- psid
Leak~ [] Did not Ope~ O Leaked =
and
Materials
Used
T~st ~ DC-Closed Closed Tight o Opened at Opened at psid
R~air Tight o psid psid
RP psid
Date ln- t accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Te~ter~ Copy