First Baptist-LR040922CtlECK ONE:
IRRIGATION
DOMESTIC FIRELINE .~
NAM~ OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
BACKFLOW PREVENTION ASSFJVIBLY TEST AND MAIN l ~:NANCE REPORT
The backtlow prevention assumbly derailed below has b~u t~'ted and r-u~.tui,cd as r~quired by. TNR.CC
ru.mdafions and is ccr~5~ to b~ opcr=fing within acc~p~bl¢
TYPE OF ASSEMBLY
[] Rcduc~ Prcssu~ Principle r~ Pr~su~ Vacuum Br~d~r
,~ Deuble Check Valve [] Atmo~pher~ Vacuum Breaker
Maaufacu~er ~C--C9 Size ~//
Mo&l Number :~ -~ '-~' Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
/:] ~, ,~ ,~ ~, Double Check Valve Assembly
/
1st Check [ 2nd Check Relief V~lve Air Inlet Check Valve
IniUal Test DC-Closed Closed Tight .)~ Opened at Opened at ~aid
i
fq)~6< T ~ ~ ~ = Leaked psid psid
' KP- /' 'paid /~, 2'
Leaked 0 Did not Open
and
Materials
Used
Test ~ DC-Closed Closed Tight a Opined at Opened at paid
Repair Tight r~ psid psid
RP paid
The above is cer~ed to be true.
., . .
Gauge~ .~ --_<,~ )
Date l~t acc~acy t~ted
Ce~t. Tezm' No,~"~6'' 5 ///7 Dm.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy