Town Center West-LR020411CtlECK ONE: /
IRRIGATION DOMI~TIC
BACKFLOW PREVENTION ASSF~LY THST AI~ .I~NTENAN~ REPORT
,,. /,/ _J I
NAM~ OF PWS:
PWS LD. #
r%,ul~ions ~md is c,~ified to be op~-afing witb~naccep~able
TYPE OF ASSEMBLY
~ l~duccd l~ssure Principle ~ Pressure Vacuum Breakcr
Double (~ueck Valve a Atmosphere Vacuum Breaker
~UCED PRESSURE PRINCIPLE A~SEMIILY PRESSURE VACUUM BREAKER
Double Check Valve Assembly,
Ist ~,,','~ 2nd Check l~,.4!,.t'Valve Air Inle~ Check Valve
Iniual Test DC-Closed ClosedTigh, ~J~~med at Opened a~ psid
Tighl d~/Lcaked' a ' psid psid
KP- ,psid
Martials
Used
T=st A~r DC-Closed Closed Tight a Opted
Repair Tigh~ al psid !~sid
IL° psid
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester~s Copy
CtlECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINf~NANCE REPORT
/
PW$ I.D. #
LOCATION OF SEI~VICE:
Thc baddlow pr~v~xfion assembly derailed below has been tcs~l md ,~i.t~i~ed as r~luired by. TN~CC
r%~lations and is certified co be operating within acccptabl.- p~,'~.
TYPE OF ASSEMBLY
a P,.educ~ Pressure Priacipl¢ ~ Prassurc Vacuum Brcak~
~ Double Check Valve ~: Au~osphcr~ Vacuum Breaker
Manufacturer ~ S~
Serial Numb=
REDUCED PRESSURE PRINCIPLE ASSEMBLY [ PRESSURE VACUUM BREAKER
Double Check V~lv, e~se~bly .
Ist Check [ 2nd Check Relief Valve A/r Inlet Check Valve
Inkial T~ DC-Closed J~losed Ti~t d' Opened at Opened at psid
Ti~t~ C[~ Leaked r~ .psid psid
ILu- psid
~ ~ Did aot
Martials
I.J.~d
T~'t ~ D¢-¢lo~ed Cloned'right ~ Op~t~at Ol~ed at ..~_~id
l~-pair Ti~t C '~sid psid
RP .- psid
Thc above is certified co be true. .~,~ ~,/ ~//~
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy
CtlECK ONE-'
IRRIGATION / D O M F-'b-i-iC
FIRELINE
BACKFLOW PREVENTION AS,$F..M~LY TEST AND MAIWI'~CE REPORT
NAME OF PWS:
PWS I.D. #
SERVICE: .
LOCATION OF ~ ~""'~
The backflow pr~veutiou assembly clcu~led below l~z bc~m ~ ~ud ~cl as ruquked by. TNKCC
rugula~ons ~r,d is ~ed to be opc~-d:i~g w~t{,{,, acc~table pa, ~,,,~,~'~.
Reduced Pressure Principle
Double Ch~k Valve
Manufacturer
Model Number
Semi Number
TYPE OF ASSEMBLY
[]
Siz~
Located At
Pmssm~ Vacuum
Atmospl~r~ Vacuum Bm. ab:r
REDUCED PRESSURE/PRINCIPLE ASSE1VUBLY PRESSURE VACUUM BREAKER
Double'Check Valve Assembly
Ist Check[ Iud Check . Relief Valve .Sir Inlet Check Valve
Initial Tezt DC-Closed Closed Tight ~'~ Opened at Op~ned at psid
Tight 1~' L~zked m psid psid
RP- psid
~ c Did not Opcu c 'I.~k~i '~
Mam'ials ~, - ~, ....
Used
Tast AY~r DC-Closed Closed Tight ~2 Opeu~[ at Opeued at psid
R~air Tight r~ psid ...... {vsid
RP psid
The above is c. em~ to be true.
Gauge # ~__
Date last accuracy tested.._~ -/7- ~ ~
White - Customer,s Copy Yellow - City Copy Pink - Tester's Copy