2011_0328CHECK ONE:
IRRIGATION (><\ DOMESTIC
FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C, appee(/1
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 be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
2r"__—Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer � 6 C Size -3/t/_
Model Number Located At F AXL-0
Serial Number ffc OL-ec-16'L
The above is% certified
to be true.
Firm Name
Finn Address 1&*YZ,
Certified Tester ��'�'`� J
Cert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
I 2nd Check:
Relief Valve Y
Air Inlet ,
Check Valve
Initial Test
DC- Closed
-C-Zsed Tight
en
d
Tight
RP- ? Ypsid
Leaked ❑
Leaked ❑
G
d
d
not en ❑
-ed ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is% certified
to be true.
Firm Name
Finn Address 1&*YZ,
Certified Tester ��'�'`� J
Cert. Tester No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy