Town Center L4B1-LR011210CtlECK ONE:
IRRIGATION
DOMESTIC ~ FIRELINE
BACKFLOW pREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backflow pruveutiou asscmb.ly derailed below has bceu tcstrd and ~.~i.t~i.ccl as r~luired by. TN'RCC
rugulariom and is c~-~Ji~d to be opcraffug w~thi, acceptable paramci~rs.
Mod~l Number
S~ial Number
Double Chemic Valve
575
TYPE OF ASSEMBLY
~ Pr~ma'~ Vacuum Br~k~r
m Atmospher~ Vacuum Breaker
Siz~ Z//
REDUCED PRESSURE PRINCIPLE ASSElV[BLY PRESSURE VACUUM BREAI~R
Double Check Valve Assembly
1st Check I 2nd Check Relief Valve Air Inlet Check
Valve'
Initial T~t DC-Clos~ Clos~ Tight t~ Op~l at Op~ at psid
Tigh~) f)~ ~ L~k~ c2 .psid psid
Mata-ials
Used
Test ~ DC-Closed Closed Tight m Opened at Opened at psid
R~air Tight ~2 psid psid
RP psid
Thc above is certified to be trim. /~ ., _
!
Date last accuracy tested 7- Z/'~)!
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CtIECK ONE:
IRRIGATION DOMESTIC
PW$ I.D. #
LOCATION OF SERVICE:
REPORT
The ba/~ow pre. ve~tion assembly detailed below has bee~ tost~d and m,l,t,~ned as required by. TNP..CC
regulatioos and is certified to be operating within acceptable pmamet:m.
Manufacturer
Mo&l Number
Serial Numbs'
Reduced Pressure Principle
Double Check Valve
/50'7 fi}L-
TYPE OF ASSEMBLY
Pr~ssur~ Vacm,m Br~ak~
Almo~phe~ Vacuum Br~l,-~r
REDUCED PRESSURE PRINCiFLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve A.ss-mhly
1st Check { 2nd Check Relief Valve Air Inlet Check Valve
Imual Test DC-Closed Closed Tight ~ Opened at Opened at psid
Ti_~t I /- ~, Leaked c~ psid psid
I, olo "' ""'"d
I,Z izaked = Did not Open ~ Leaked
Materials
Used
Test ~ DC-Closed Closed Tight ~ Opened at Opined at psid
R~pair Tight ~ psid psid
RP psid
\%
The above is co'~ied to be true.
Fi.,'mName ~// '-7~e~ CertifiedTe~:r
FirmAdd~ss ~a' ~/53~ C~T~No.
D.te Et'.cc,,.cy t~t~d ---/' Z/- O /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
CfIECK ONE:
IRRIGATION DOMESTIC FIRELINE ~
BACKFLOW PREVENTION ASSF. MBLY ~ AND MAINI]~IANCIg REPORT
~,~o~w~:(.,'.l~/ ~,~c r,.,~,:,~'!l ~,,~,~'.~
PWS I.D. # ~X'%~
The badcflow prevention ~ss~mh.ty d~tailed below has been ~ and malntaincd ~ ~ by. TNRCC
r~bmlafions and is e..~'fi.fi~ to b~ operating ~thi. accxptable p~, ~a~n~rs.
Maaufactm'~r
Mo&l Number
S~riai Number
TYPE OF ASSEMBLY
m Pressure Vac,-,'~ Braaka'
t2 A,mosph~ Vacuum Breaka'
Siz: (Q tr
L~.=i^, Va.I-/-
REDUCED PRESSURE PRINCIPLE ASSEI~BLY PRESSURE VACLrUM BREAKER
Double Check Valve AS.omh{y
Ist Check ] 2ad Check Relief Valve Air Inlet Check
Valve~
Iaiual Teat DC-Clos~ Closed Tight XOpted at Op~n~i at l~sid
~/,o/~ ~g/'?=d~ ~.~ 0 ° ~d ~s~.d
Materials
Us~cl
T~'t ~ DC-Clos~I Clos~l Tight aOp~l at Op~ at psid
R~air Tigi~ ~2 vsid vsid
RP psid
The above is certified ~ be
c,.~ge # 00-)1~.1
Date last accuracy tested
C~fled Tes~
C~t. Tes~r No.
White - Customer~ Copy Yellow - City Copy Pink - Tester~ Copy