St Joseph-LR040225~HI~CK ONE':
IRRIGATION
DOMESTIC FIR~!JNE
BACKFLOW PREVENTION A~EM~LY TEST AND MAI~I~~- REPORT
PWS I.D. #
LOCATION OF SERVICE:
The b~.kflow prevenfiou vzs~mbly d~miled bclow has been test~l and maintain~l as requ~d by. TNKCC
re~d~aco~ m~i is c~dfied ~o b~ op~a~g w/~/~ __~cc_~able pm-~ne~rs.
~ Pressu~ Principle
Double Check Valve
TYPE OF ASSEMBLY
_ 12 Pr~ssw~ Vacuum Br~mlmr
u Ammspba~ Vacuum~mal~r
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check [ 2nd Check Rellef V~ve Air Inlet
Iuiti~lT(mt DC.Clos~/ 'Clos~tTight ~/Opm~l~t Opcmxl~t psid
Ti~h~ ~' L~k~d 0 psid psid
KP- psid
U~zd
T~t.t~ DC-CIos~i (~clTi~h~ o Opm~cla~ O~a~ psid
P,~air Ti~h~ o psid psid
P.P psid
Thc above is cc~ified to be uvc.
Date last accuracy tested
White - Customer~ Copy Yellow - City Copy Pink - Tester~ Copy
IRRIGATION 7
DOMESTIC
FIRELINE
BACI~I~OW PREVENTION ASSF_.M~LY TEST AND MAINii~NANCE REPORT
NAME OF PW$:
PWS I.D. #
LOCATION OF SEKVICE:
Redue~ Pressure Principle
Double Check Valve
Fe..bco
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size
S~rial Number ~'~o-7C~
REDUCI/D PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACULrM BREAKER
/
Valve Assembly [
Double
la Check 2,,d Check , Relief Valve Air Inlet ~'~ Vsl~e
Im~ial Test DC-Closed Closed Tight ~/ Opined at Opened at .psid
Tigi~ ~/ Leaked o psid psid
R.P- psid
Leaked O Did not Opm 0 ~ O
and
Mam, ials
Used
Test ~ DC-Closed Closed Tight 0 Opened at Opened at psid
l~'pair Tight r~ _ psid psid
RP osid
The above is cerdfied ~o be m~e.
Date last accuracy tested
White - Customer's Copy YeUow - City Copy Pink - Tester's Copy