Town Center L4B1-LR011206CHECK ONE.'
IRP, JGATION
DOMESTIC
FIREI,INE'
BACKFLOW PREVENTION ASSEWI~LY TEST AND MAINTENANCE REPORT
The back. ow preve~tio~ assembly detailed below has bee~a tested a~d mainr~ed as required by. TNRCC
r%mal~mo~s and i~ certified to be operating within acceptable pa~ .metes.
Maaufacturer
Model Number
Serial Number
R~duced Pressure Principle
Double Cher~ Valve
TYPE OF ASSEMBLY
Pressure Vacuum Bruak~
Atmosphere Vacuum Breaker
~
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESS~ VACUUM BREAKER
Double Check Valve Assembly
Ist Check I 2nd Check Relief Valve .Mr Inlet Check Valve
Iuiual Te~t DC-Closed ~losed Tight ~f'{ Ol~ued at Opened at psid
TiM . ~ ~
and
Ma~rial~
T~: ~ DC-Clo~ed Closed Tight 12 Opted al: Opined at p$id
l~air Tigt~ ~ psid p~id
RP p~id
The above is certified to be true.
FirmAddr~s ~a,~, ~,~!Z~--~' Cer~ Test~rNo.
Date ~t acc~acy t~ted 7--21~/
Ce~fied T~s~r //~/~
?.5z7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CtIECK ONE:
IRRIGATION
DOMESTIC
FIREI~INE~
BACKFLOW PREVENTION ASSF..ROILY TEST AND MAIN ie;NANCE REPORT
PWS I.D. #
The bacl~ow prevenl~on assemb.ly defiled below has bee~ ~ and maima~ued as r~!uired by. TNRCC
re_m~la~o~s a~d is certified to be opo-a~g within acceptable pa~
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve A.~emhly
1st Check [ 2nd Check Relief Valve .~[r Inlet Check
Valve'
biual Test DC-Closed J Closed Tight ~' ~Opened at Opened at psid
Ti~fit~,~,~ m Leaked m psid psid
~ ~2 Did not Open
and
Mat~"ials
U.~d
Test ~ DC-Closed Closed Tight m Ol:~d at Ol~n~ at p~id
~ R~pair Tight ~ p~id p~id
RP
T~e above is certified to be true.
Oauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CtlECK,ONE:
IRRIGATION
DOMESTIC
FIREIJNE' :'"'" "~
NAIVI~ OF PW$:
PWS I.D. #
LOCATION OF SERVICE:
BACKFLOW PREVENTION ASSEMBLY I'F_~? lhl) MAiN'r ~:NANCE REPORT
The back/Iow prevenlion assembly derailed below has been tesmd and m~inr.i.ed as required by. TNRCC
re.~la~ons and is cer~fied to be operating within acceptable ps ~.~eters.
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Amaosph~re Vacuum Br~al~'
REDUCED PRESSURE PRINCIPLE ASSEMBLY P~SURE VA~ BREAKER
Double Check Vnlve Assembly ' i~ ~ ."
1st Check I 2nd Check Relief Vnive Mr In~ ~ , Check Valve
Im~ial Test DC-Closed .,~ Closed Ti~t ~ Open~ ~t Opened az psid
Tight · ~ L~k~d psid psid
Martials
Used
Tast A.t~r DC-Closed Closed Ti~t ~ Opted at Opm~ at psid
R~pair Tight n psid ==_~=.__psid
RP psid
The above is certified to be true.
Date l~t accuracy t~ted
Certified Taster
Cert. Taster No.
7-Zl-O I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREvENTIoN A~$EMBLY TEST AND MAINi'~N~CE REPORT
PWS: C.' o
PWS I.D. #
The bac.~ow prevention assembly dehailed below has been tasted a~d m.i~t~inex] as requital by. 'rNR. CC
r~.~lalio~ and is c~r~ed to be operating w~thi, acc~table parameters.
Manufacturer
Mo&I Number
S~mal Number
Kedu~ Pmssur~ Principle
Double Ch~ck Valve
TYPE OF ASSEMBLY
Pressure Vacuum Brrak~
Atmospher~ Vacuum Br~
REDUCED PRESSURE PRIN~lrLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check ) 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC-Closed , Closed Tight /~ Ol~ned at Opened at psid
~. L~aked ~ psid psid
~Q.] /0[ Tightl ~psid
/0 RP- ~,~
Leaked a ' Did not Open
Materials
Used
ii~ ~ Opined at Opined at psid
T~st
DC-Closed
R~air Tight tn'~l~/ psid psid
RP psid
Thc above is certified to be
Finn Adch'~s ~/)' ~5o,~
~~ 007100/
Date ~E~e~ t~ted
~Nte - O~tomer's
C~ed T~-t~r
C~rt. Tear No.
Yellow - City Copy
Pink - Tester~ Copy