Freeport NIP(2.4)-LR001002CtlECK ONE:
IRRIGATION
DOMESTIC FIRELINE /
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
BACKFLOW PREVENTION A~SF..M~LY TE~T AND MAINI'~CE REPORT
The back-flow prev=ntion assembly ~il~i below has been m~d and m,l,t,l,ed as mquirui by. TNRCC
re.~lalions and is canified w be o!~rafing w/thin acceptable parame~rs.
Manufacturer
Mod~l Number
S=ial Number
Raducad Pressure Principle
Double Ch~k Valve
TYPE OF ASSEMBLY
Prassur~ Vacuum Brral~r
[] A-nosphere Vacuum Breaker
REDUCED PRESSURE PRINCIPLE ASSEI~[BLY PRESSURE VACUUM BREAKER
Double Check Valve Ass~,nbly
ls~ Check I 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Tight ~' ~Opened at Opened at psid
Ti~h~ ~ Le. ak~i ~ psid psid
PP- psid
Leaked ~ Did not Open a Leaked =
Mau:rials
Used /
Tas~ Afar DC-Closed /Closed Tight ~ Opted at Opted at psid
R~air Tigh~ ~ psid psid
RP psid
lO -D.
Date l~st accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy