Cici's Addition-LR 991206CtlRCK ONE:
IRRIGATION
DOMF~'TIC
BACKFLOW PREVENTION A,,~'EMBLY ~ AND MAi~i-~CE REPORT
PWS I.D. ~
LOCA O OF s ,acE: 1080
The bact~ow prevention assembly derail~ below has been ~ and ~ed as requfl'~ by. TNRCC
rc_m,tlafio~s and is ca'lifted ~ be op~"a~g withi,u acceptable pa~ ~,i,,~rs.
TYPE OF ASSEMBLY
R~duc~l Pr~,surc Principle ~
Double Check Valve ~
Manufaclur= ~ ~_.~' _5 ~_ tt /
Modal Number ~
Siz~
Located At
l~ressur~ Vac~.m~ Br~le~'
Armosph~r~ Vacuum B~ak=
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Ass-mhly
Ist Check { 2ad Check Relief Valve A/r Inlet
Valve '~.,
InitialTest DC-Clos~i ~Clos~dTight ~' Open, dar O~nedat psid
Tight a/ L~ked ~ psid psid
RP- psid
Mak~ ~ Did not Op,'-
Mg~'iais '"
{Used
T~st At~ DC-Clos~d Closed Tight u Opted a~ Opted a~ psid
R~air Tight ~ psid psid
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Testers Copy
CH~CK ONE:
IRRIGATION
DOMESTIC
The ba~flow pr~v~ion assembly detailed below has been tested and m~i~taiaed as r~lUired by. TNRCC
r~gulagoas and is c~cifi~ to be operating within acceptable parameters.
Double Ch~ck Valve
Model Number ~ec~
TY~PE OF ASSEMBLY
Pr~st~ Vao~,m Br~lmr
Armosph~r~ Vacuum B;~.,ak~r
REDUCED PRESSUR~ PRIN~LE ASSEMBLY PRESSUR~ VACUUM B~R
I~ ~ [ 2ad ~ ~d V~e ~ ~et
V~e'~
~ T~ ~-CI~ CI~ Ti~ ~ ~ ~ ~ a psid
Ti~ ~ ~ ~ psid psid
~- psid
~ ~ ~ ~d not ~
U~
T~ ~ DC-CI~ Cl~ Ti~ a ~ a ; ~ ~ pgd
~ Ti~ a pgd
~ psid
Thc above is certified to be true.
Date last accuracy tested
White - Customers Copy Yellow - City Copy Pink - Tester's Copy
CtlECK ONE:
IRP, IGATION
DOMI/STIC FIRELIlqE /
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTF. NAN~ REPORT
! I~
PWS I.D. #
.oc^uo o sn cs: cO. +¼e.I
The bacldlow l:r~v~fion assembly de~ailed below has been tested and ~ed as ~ by. TNKCC
r~.ellaons and is c~ifi~d to b~ olxraing withi~ acc~ptabl¢ parameters.
TYPE OF ASSI~vfBLY
l~ssurc Vacuum Bnmk~r
Atmosph~r~ Vacuum B~akcr
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI~R
Double Check Valve Assembly
Is~ Check ~nd Check ReUef Valve Air I~let Check Valve
Ink/al T~s~ DC-Clos~d · Closed Tight ~// Opened a~ Opened at psid
Ti!tg al/ Lcal~ ~ psid psid
RP- psid
Leaked r~ Did not Open m Leakexl
Used
Test After DC-Closed Closed Tight o Opcn~ ~ Opened ac psid
Repair Tight o psid psid
RP psid
The above is certified to be true.
!
F~'L~,~%v;lle~ 7~ C~
Gauge#
Date la.st accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy
CtlECK ONE:
I~KIGATION DOM]~f'IC lqRELIHE ~/
BACKFLOW PREVENTION A..~SEM~LY TEST AND MAINTENANCE REPORT
NAMtl OF PWS:
PW$ I.D. #
LOCATION OF SERVICE:
R~,__,~ Pressure Prim:iple
Double Ch__~_.k Vdv¢
Manufa~urer [-{e r
/
RKDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRF. AK~R
Double Check Valve Asr~mhly
Ist Check 2nd Check Rellef Vatve Air Inlet
Imual Test DC-Closed Closed Tight ~/ Opened at Op~m~cl at psid
Tigh~ ~/ ~ o psid psid
KP- psid
Lea~d ~ Did not Open
Mata-ial~
Used
T~t Afar DC-Closed Clos~iTight o Ol~n~i at Ope~d at psid
' R~air Tight ~ pdd pdd
Thc above is certified ~o be mm.
'lD. O. 'l:~y, ~ 3f~,.'.4 ~ T,.,,,.N0?CoO$~d~f~ I
Gau~e # ~ l~TI
Date last accuracy tested
White - Customers Copy Yellow - City C_~py Pink - Tester~ Copy
CilECK ONE:
IRRIGATION
DOMESTIC / FIRELINI~
NAME OF PWS:
PWS I.D. #
LOC^UONO S V CS: I0 80 cO, 'bm-he
Thc bae&-flow prev,~t/on assembly det~ed below has been testat and -.,i.t.~.ed as requir~t by. TNRCC
r~flations and is canifled to be opcr'atmg wit~i- acceptable p~,,~ct~rs.
Manufacturer
Mo&l Number
S~iai Number
TYPE OF ASS]Rvfl3LY
m Presort Vacuum Breaker
[] Atmosphcr~ Vacuum Brcal~r
Sm ~"
REDUCED PRESSURE PRINCn~LE ASSEMBLY PRESSLrRE VA~ BREAKER
Double Check Valve AS.~"mhly ~'~,
1st Check 2nd Check Relief Valve Air Inlet Che~k ValVe~
Initial T~t DC-Closed Closed Tight ~1/ Opened at Opened at psid
Ti~t a/ Leal~ o psid psid
KP- psid
Leal~ ~2 Did not Open r~ Leaked
Materials .
T~st Ai~ DC-Closed Closed Tight o Opened at Opened at psid
R~air Tisht n .____~psid psid
RP psid
The above is certified to be tr~.
!
~..O. ~ × ,,,~ 3~'-/[ _ , Tester No?_~GO G;
FJrm A&~ L t;, , ~ ; ~ v,'t l e.,'-'F~ v~.i,z~ Ce~t. Dam
Gauge # (-3~l(~OVI
Date last accuracy tested
White - Customer~ Copy Yellow - City Copy Pink - Tester*s Copy
CIlECK ONE.'
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
~*~m O~ ~WS: C~+~ alz C~oe 1 [ ,~x.
PWS I.D. ~
Thc bactdlow pr~v~ion ass~nbly detailed below ha~ be~n tm~d and m,lnr,ined as r~quimi by. TNKCC
r~gulahons and is calified to be operating within acceptable
~ l~u~d Pressure
· ~ Double Chew~ Valve
TYPE OF ASSEMBLY
I2 Pr~sure Va;u~um Br~ule~r
~ Almosphere V~
S~ ~"
Serial Number tO q. [ l oC3
~UCED PRESSLrRE PRINCIPLE ASSEi~BLY PRESSLrRE VACUUM BREAKER
Double Check Valve Ass~",nhly
1st Check ] 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC-Clos~ Closed Tight ~ Opted at Opened at ________psid
Tigt~ ~/ Leaked c~ psid psid
KP- psid
L~aked a Did not Open
and
Materials
Used
Test After DC.Closed Closed Tight c3 Opea~i at Opted at psid
tkpair Tight a _~_~psid psid
RP ps-id
The above is certified to be ~ue.
Gauge # ~
Date last accuracy tested
White - Customer~ Copy Yellow - City Copy Pink - Tester~ Copy
CHI~CK ONE:
IRRIGATION'
DOMESTIC
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINi~ANCE REPORT
NAME OF PWS:
PWS I.D. ii
LOCATION OF SERVICE:
The bac. ldl~ prevention assembly detailed below has been test~l md ~ed as required by. TNRCC
r%~b6ons and is certified ~o be opcr~ing v~thl, ar..~ptable p~'u~.
Double Check Valve
Model N~mber D ~ ~ "~',/~
S~riai Number
TYPE OF ASSEMBLY
Pr~ssur~ Vao-~ Breaker
[] A,',,,osph~e Vacuum
Siz~
Locat~l At
REDUCED PRF_.~URE PRINc~LE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Ass-~hly
1st Check [ lind Check Rgief Valve Air Inlet Check
Valve~
Initial Tcs~ DC-Closed Closed Ti*~,- = ~ at '~ at '~,._~.osid
Tiaht r~ Leaked - ~ '-'~sidNN psid
1~- (~) osid~//
I. caked Did not ~ Leaked
and h,~br Froa"-
Mat=i~ls ~ ,..,~ 'k %
Used ~ / Cb.¢ck L~.c.,(
T~tAt~r DC-Clos~d aosedTi~ht ~'/-Ol~..edat !Openedatpsi~ '
RP ~', o psid
The above is c=tificd to be true.
Date last accuracy tested
White - Customer~ Copy Yellow - City Copy ,. Pink - Testur's Copy