2011_0407CIIECiK ONE:
IRRIGATION DOMESTIC FIR ELYN E
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D. #
LOCATION OF SERVICE: -- '
"The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Va�-�n***+ Breaker
-� Double Check Valve D Atmosphere Vacuum Breaker
ManufacL}ser ` _ S� e -
Model Number
Serial Number
u
Located AL - '
The above is certified to be true_
Firm Name —Ji�%� � � �� �\ Certified Tests � � � ���p � �
Firm Address � 9a� � u �'�� Cert Tester No. `'?��-��' � �� Date '— % —(
Gauge # 3 � ? � Ste' Cam„- 3 p � �
Date last accuracy tested ��— t t � ( Q
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR��F'R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight Q._
Opined at
Opened at
osid
Tilt a ""
RP -. �' �? vsid
_Closed
Leaked a
psid
vsid
Leaked a
Did not Opm [7
Leaked �
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
vsid
Repair
Tight �
nsid
vsid
RP sid
The above is certified to be true_
Firm Name —Ji�%� � � �� �\ Certified Tests � � � ���p � �
Firm Address � 9a� � u �'�� Cert Tester No. `'?��-��' � �� Date '— % —(
Gauge # 3 � ? � Ste' Cam„- 3 p � �
Date last accuracy tested ��— t t � ( Q
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy