Lam Lee-LR000907CtlECK ONE:
mRIGATION
DOMESTIC FIRELINE
BACKi~OW PREVENTION ASSEMBLY TEST AND ~ l ~:/~[ANCE REPORT
PWS I.D. #
LOCATION OF SERVICE:
The back-flow prevention assemb~ detailed below has be~m ~ and m,i~t,i~ed as ~ by. TNRCC
z~_~l~o~ ~ is c,~'tifi~ to be operating ~,hln acceptable param~.
TYPE OF ASSEMBLY
~ Keduced Pressure Principle ~
~ Double Check Valve ~
Manufacturer ~ ~./~ ~IA'~ ~ ~ Siz~
Model Number ~'~,~"~1) ~/., Located At
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
2,
REDUCED PRESSURE PRINCIPLE A~SEMBLY PRESSURE VACUUM BREAKER
Double Check Vsive Assembly
1st Check [ 2nd Check Relief Valve Air Inlet Che~.k V~lve
Initial T~st DC-Clos~i Closed Tight ~' ! Ope~l at Opeued at psid
Ti~t ~' Leaked cl psid psid
KP-~sid
Leai~ c: Did not Ope~ cn I.e. ak~d ~
and
Materials
Used
Test ~ DC-Closed Closed Tight ~ Opened at Op~n~d at psid
' P,~-pair Tight a psid psid
RP psid
The above is certified ~o be u~.
C~t. Tes~rNo. 4~l~'z~P~CiTDm ~- 7-'C~0
D.te last
White - Customer's Copy Yellow - City Copy Pink - TestePs Copy