MA 9601-LR021125· Dec' 23 02 08:26a
C~IECK ONE:
IRRIGATION
Dentex / Double Check 940-387-8787
DOMESTIC FIRELINE
BACKFLOW PREVENTION A~EMBLY T~$T AND MAINTE~ REPORT
NAM~ OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
Thc backtlow prevention ass~'~bly dezailed below has b~ tested and m,{-~,~n~ as rex~ by. TNRCC
regulations and is certified to be operating wi~{,, acceptable paramet~s.
M~uufacmrer
R~iuc~ Pressure Pri~iple
l~uble Che~;k Valve
TYPE OF ASSEMBLY ~ P~-ssur¢ Vacuum Breaker
$ A~morphcre Vacuum Breaker
Model Number
Serial Number
La:amd At
REDUCED PRESSUI~ PRINCII~LE ASSEIVIBLY ] PRESSUR~ VACUUM BREAt~R
Double Check Vslve Assembly
ls~ Check I 2nd Check Relief Valve Air Inlet Ch.eU Valve
I~i~al Te~t DC-Closed Closed Tight ~ Ope~od at Opcued at psid
Ti~hl /~.~sid ~ L~ed 0 psid osid
Lcakc~ 0 Did not Open e: Leaked
and
Materials
Used
Test ~ DC-Closed Closed Tigh~ o Opened at Opted at psicl
R_~air Tight m psid psid
RP psid
The above is c.~ified to bc ~rue.
Date last accuracy tested '.~.~/D., ~-~
White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy