First Baptist-LR040922 (2)Ctll/CK ONE:
IRRIGATION
DOMESTIC FIRELINE /~,
BACKFLOW PREVENTION ASSEMBLY TEST AND ~ l ~NANCE REPORT
NAME OF PWS: ~-.~f~ e'//
PWS I.D.
OCAnO S mC :
The bad, low prevention ass~bly de~fled below ha~ been ~ and m~inrai.ed a~ ~ by. TNRCC
regulafiom and is cerdfied to be operafiag w~thln acceptable parameters.
[]
Manm~acturer
Mod~l Number
S~fial Number
R~uc~ Pr~su~ Principle
Double Check Valve
TYPE OF ASSEMBLY
[] Prussur~ Vacuum Breaker
[] Aunospherc Vacuum Brcak~
Size ~' '''
Located At ~e~ .//'
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
?~7~ Double Check Valve Assembly
1st Check I 2nd Check Relief Valve .Mr Inlet Check Valve
Iniual Te~ DC-Closci t Closed Ti~t ~ Opted at Opened at psid
Ti~x /J, ~ ~ Leaked [] psid psid
Leaked c~ , Did not Open m L~ak~d m
Materials
Used
Test ~ DC-Closed Closed Tight m Opened at Opened at psid
R~pair Tight m psid psid
RP psid
The above is ceni~ed to be true.
Date ~t accuracy t~ted :~ ~ -~ y'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy