2011_1107CiIECI� ONE:
IRRIGATION DOMESTIC
I;� 1:3 Di w :ice
BACKFLOW PREVENTION ASSEI��LY TEST AND MAIl�lTENANCE 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 certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
O Reduc. -d Pressure Princivle � Pressure Va�ru� Breaker
E7 Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer �� �� Size
Model Number �/ - e Located At
Serial Number � -G� � � C�
The above is certi.f ed to be true. ��
Firm Name ��� Certified Tests � ��
Rlchmrlson, Tx. 7Sas2 Q /
Firm Address CerL Tester No. �'7 ��� � / S L Date //- �— /
Gauge # �/ 7 � �� ��� Q �C4.J
Date last accuracy tested � Z —� L %lv
T
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_AT�'R
Double Check Valve Assembly
1st Checl:
2nd Cheki:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight .��
Opined at
Opined at
osid
Tight , �
Leaked �
psid
osid
RP- - osid
Leaked o
/
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Ai3rs
DC- Closed
Closed Tight o
Opmcd at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The above is certi.f ed to be true. ��
Firm Name ��� Certified Tests � ��
Rlchmrlson, Tx. 7Sas2 Q /
Firm Address CerL Tester No. �'7 ��� � / S L Date //- �— /
Gauge # �/ 7 � �� ��� Q �C4.J
Date last accuracy tested � Z —� L %lv
T