Town Center West-LR020411 (2)CtIECK ONE:
IRRIGATION DOMESTIC FIRELINE /~
BACKI~OW PREVENTION A~SF.,IV~LY TEST AND MAI~i'~NANCE REPORT
PWS I.D. ~
~e b~ow p~v~fion ~s~bly de~ below ~ b~ ~ ~d ~,i~t,i,~ ~ m~ ~ ~CC
~o~ ~d ~ ~ to be op~g ~t~i~ ~mbl~ p~.
Manufacturer
Model Number
Serial Number
Reduced Pressure Pr'maple
Double Check Valve
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
[] Atmosphere Vacuum Breakex
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Vslve Assembly
ls~ Check [ 2nd Check Relief Valve Air Inlet
Check
Valve
hamal~.~,~_)Test DC-Closed ~. ~/, Closed Tight ~/ Opted at Op=ed at psid
Ti_~hI Leaked a .psid psid
Materials ~
Us~
Test Afl~ DC-Closed Closed Tight ~ Op~n~ at Op~n~ at psid
l~alr Tight ~ psid paid
I~ psid
The above is certified to be ~.
Gauge ii ~
Date last accuracy tested
Tes rNo. Z'/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
NAME OF PWS:
PWS I.D, #
LOCATION OF SERVICE:
BACKFLOW PREVENTION ASSEM]BLY TEST AN]D MAINTENANCE REPORT
The bac2~ow privation ass~ably detailed below has b~a ~ and m~intamed as r~quir~ by. TNRCC
mgula~ons and is ~xified to be op~raUng W'~thi,n acc~rable pamm~'~rs.
P,~uc~ Pr~sur~ Principle
Double Ch~ck Valve
TYPE OF ASSEMBLY
Pressure Vacuum Breakm'
Atmosphere Vacuum Breaker
Mma~acmrer /~/'k'/~=~=:~ Size
REDUCED PRESSURE PRINCIPLE ASSEM]BLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check I 2ad Check Relief Valve .4Jr Inlet Check Valve
Imnai Test DC-Closed ,~/.4~ Closed Tight ~ '~'Opcned at Opened at psid
~) Tight ~" Leaked ~ psid psid
I~- psid C:~-°Q' Did not Open :2 Leaked ~
and
Matmals
Used
T~t ~ DC-Closed Closed Tight c~ Opined at Opined at psid
R~air Tight ~ psid psid
RP psid
The above is certified to
Gauge #
Date last accuracy tested '~-~
Cert. T~'t~r No.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CtlECK ONE:
IRRIGATION DOMESTIC FIRELINE e/fi'
NAME OF PWS:
PWS I.D. #
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
The bad,.-flow prevenI~on assembly derailed below has bee= tes-,~d and mnintz½nc:d as r~q~ by. TNRCC
re_mflanons and is certified to be operating within acceptable pwametrrs.
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Ek, uble Check Valve
/._/,q
OO/c 7
TYPE OF ASSEMBLY
Pressure Vacuum Breat~r
Armo~h~re Vacuum Breaker
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
SO Double Check Valve Azsembly
1st Check J 2nd Check Relief Valve Mr Inlet Check
Valve
ImUal Test DC-Closed ~'o~- Closed Tight ~' ~Op~ed at Opened at psid
.~") Tight ~ Leaked : psid psid
R.P- psid
L~.ked [] ff.~ _ ~ Did not Open ~ I.~aked fl
a~d
Mammals
Used
T:st ~ DC-Closed Closed Tight m Opeaed at Opened at psid
R~pair Tight m psid psid
~ psid
The above is certified to b¢ mae.
oauge #
Date l~t accuracy tested
Cert. Tes~ No.~9 7~ gt,~ ~ Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CtlECK ONE:
IRRIGATION
DOMESTIC FIRELINE X
BACKFLOW PREVENTION ASSElVIBLY TEST AND MAI2VI NANCE REPORT
PWS I.D. #
LOCATION OF SERVICE:
The back. ow prevention assembly derailed below has been ~ md rnaimal.ed ~ req~fi~l by. TNRCC
regmianon~ ~md is certified to be operating within acr.~pmble p~emm.
Manufacturer
Model Numbe~
Serial Number
Reduced Presmme P~uciple
D~uble Check Valve
TYPE OF ASSEI~fBLY
l>resvare Vacuum Breaker
Atmosphere Vacuum Breaker
size
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSLrRE VACUUM BREAKER
Double Check Valve A~$~mbly
Ist Check [ 2nd Check Relief VaJve Mr Inlet Check Valve
ImUalT~t DC-Clos~da~- I !Closed Tight l:~'Op~edat Openedat psid
/_~/a) Ti_flat ~;~ Leaked ~ .psid psid
R.P- psid ~Q
Leaked 12 Did not Open r~ Leaked
and
Materials
Used
Test After DC-Closed Closed Tight rn Opined at Opined at p$id
R~alr Tight rn p$id psid
RP psid
The above is certified to bc mm.
/
Date l~t accuracy t~ted
Cert. T~ No. ~
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy