St Ann Catholic-LR011008 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE .~'C ~
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
\ -
PWS LD. #
The bade[low prevention assembly detail~i below has ~ testrd and maintalpecl as mquim:t by. TNRCC
m_m. dation$ and is certifi~:t to b~ operating within acceptable p~amefga's.
Keduccd Pressure Principle
D~uble Check Valve
Manufacturer /~ ~cO
Mod~lNumber ~/~f¢ 112,'a.r /,3,
Serial Number ~/are /l'/,'~x~',~
TYPE OF ASSEMBLY
2 Pressure Vacuum Bmak~
r~ Atmosphere Vacuum Breaker
Size ~ #
REDUCED PRESSURE PRINCIPLE ASSEM~BLY PRESSURE VACUUM BREAKXR
Double Check Valve Assembly
Ixt Check I 2nd Check Relief Valve .Mr Inlet Ch~el, Valve
Imtial Test DC-Closed Closed Tio~at i~ Opened at Opened at psid
Tight ,2. / 1~ Le.~ked ~ .psid .osid
~ d RP- psid I.I
55 Leaked ~ Did not Open r2 Lr. ak~
and
Mat~ials
Used
Test ~ DC-Closed Clos~l Tight ~ Opened at Opm~t at psid
R~air Tight cl psid psid
RP psid
The above is cctaffi~ to be t:ru~.
Gauge#
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy