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Lam Lee-LR000907 (2)CiI, ECK ONE: IRRIGATION DOMESTIC FIRELINE NAME OF PW$: PW$ I.D. # LOCATION OF SERVIC£: BACKFI~W PREVENTION ASSEMBLY TEST AND MAINf~CE REPORT S. o.a( La. ! Tho backflow privation assembly detail~i below has b~n test~l and m~i.~i.~l az ~ by. TNRCC r~gulations and is c~fifled to be operating ,,,h~hln acceptable p~rs. Manufacturer Mod~l Number S~rial Number l~iuced Pr~sur~ Pr/nc/pie Double Ch~k Valve TYPE OF ASSEMBLY Pressure Vacuum Brea~r [] Atmosphere Vacuum Breal~r REDUCED PRESSURE PRINCIPLE ASSEMBLY ; PRESSURE VACUUM BREAKER Double Check Vslve Assembly Ist Check [ 2nd Check ,Relief Valve .Sir Inlet Ch~k Valve Imtial Test DC-Closed/ 'Closed Tight ~f/ Ol~d at Opened at psid Tight ~t l.w. aked c~ psid psid RP- psid Leaked t2 DidnotOl~n n L~aked ~ Materials Us*d T~st ~ DC-Closed Clos~ Tight o Op~n~d at Opted at psid R~pair Tight t~ psid psid RP psid Gauge Date last accuracy tested ~ - /~. ~ White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy CHECK ONE: IRRIGATION DOMESTIC / FIRELINE NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: BACKi~OW PREVENTION ASSEMBLY TEST AND ~ i'~NANCE REPORT o 4 Coe t( The bacJ.'flow prevention assembly detailed below has been tez~d and m~i,,p~i,,,:xi as ~ by. TNRCC mgulai/ons and is certified to be opening w/thin acceptable parameters. Manufacturer Model Number Serial Number l~duc~ Pressure Princ/pl¢ Double Chcck Valve TYPE OF ASSEMBLY Pressure Vacuum Break~ Atmosphere Vacuum Bre~t-~- REDUCED PRESSURE PRINCIPLE ASSEIV[BLY PRESSURE VA~ BREAKER Double Check Valve Assembly Ist Check 2nd Check Relief Valve Air Inlet Check Valve ' Im~al Te~ DC-Closed /Closed Tight ~/ Opted at Ope~t at psid Tig~ ~/ L~aked o psid psid KP- psid Le. ak~l ~: Did not Open c: ~ ,~ Martials Uscd Test ~ DC-Clos~I Closcd Tigh~ c~ Opted at Opcned a~ psid Repair Ti.gl~ o psid psid 1~ psid The above is certified to be u'ue. FirmNamc '~l,-S~'v'v'~gt:~Lk'~(O..O CcnifiedTc~tcr ~ FinnAdd~ss ~...dt%v;tl~'~"cA ~ C~t. Test~No.Ar~Dat~ (~---'7 ~ Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester% Copy CtlECK ONE-' IRRIGATION DOMESTIC FIRELINE V/'' PWS I.D. # LOCATION OF SERVICE: The back'flow prevention assembly detailed below has bce= tcstcd and m,i,,r~i,,cd as required by. TNRCC re~,lllation$ alld is ccrti,fied to be opcFatillg within acceptable pa~,.,,,ctcrs. Model Number S~i~i Number TYPE OF ASSEMBLY Double Chcck Valve Siz~ Located At Pressure Vacuum Brcakcr Aunosphcre Vacuum Breaker -%-, REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUIVI BREAKER Double Check Valve Assembly Ist Check 2nd Check , Relief Valve Air Inlet Check Valve hfitial Teat DC-Closed ~Closed Tight ia/ Opened at Opened at psid Tight ~r' Lcatad iD psid psid RP- psid Lcaked ~2 Did not Open o Leaked ~ Materials Used T~t Ai~ DC-Closed Closed Tight ~ Opened at Opcncd at psid Repair Tight o psid psid RP psid The above is ccrtified to be true. Finn~ Date last accuracy tested ~-~ - White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CtIRCK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TF~T AND MAINi~<NANCE REPORT NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: C -I-y o_,C Cop? l ! The backflow prevention assembly detailed below has been testexi and maintained as r~quir~d by. TNRCC r~gtllal:iolls aud is cerl:~ed to be operating within acceptable parameters. Ma~ufa~urer Model Number Semial Number l~uced l~ssur~ Pm~:ipl¢ Double Check Valve TYPE OF ASSEMBLY Pressur~ Vacuum Brezk~r Atmosphcr~ Vacuum B~ REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Ist Check [ 2nd Check Relief Valve Air Inlet C%,ek Valve Iaitial Test DC-Closed Closed TightEl/ /Opened at Opened at psid Tight cl Leaked ~' psid psid PP- psid ~/ / Leak~ Did not Opera al Leaked Materials Used / Test Alter DC-Closed ~losed Tight ~/ O!~ned at Opined at _______psid R~alr Tight ~ psid psid RP psid Gauge # ~ Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy CIIECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN l ~:NANCE RF. PORT PW$ I.D. # ~oc^'~oN o~ s~awcs: ~ ~ Th~ ba,.k~low pr~v~utiou ass~nbiy d~tailed b~low I~ ~ t~ ~ud ,,,,~,t,~,,~ as ~ ~ TNRCC mguhtious and is c.~'fifi~ to t~ OlXU'ati~g ~thin ~.~'ptable pmk. Manufacum~ Mod~l Number S,~'iai Number TYPE OF ASSEMBLY R~uc~d ~ssu~ Principle o Double Ch~k V~Iv¢ o Pmssu~ Vacuum Au~osph~r~ Vacuum B~ 314', ftc{ REDUCED PRESSURE PRINCIYLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check V~lve Assembly 1st Check [ 2nd Check 4~ellef Valve .4Jr Inlet Check Valve Init/al T~ DC-Closed ~Closed Tight ~/ Opcued at Opened at ___~__psid Ti~ ~" L~cl o psid psid RP- psid ~ o Did not Open Ma~'ials Used Tcs~ ~ DC-Closed Closed Tigh~ o Opened at Opted at psid R~ir TiCu o ~sid ~sid I~ psid FumAd~sm Leu.~,,~, Lt~ %Y,,7~C~t.T~mt~-No.'~t.m~,,o Dau~ Date ]~st accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy