2011_0302CHECK ONE: G��
IRRIGATION y DOMESTIC FIRELIN
E
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: // // X� //, �
PWS I.D. #
LOCATION OF SERVICE: �Z, it / -5
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
q,/ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ��" Size
Model Number Located At s•�f
Serial Number7.3%
The above is certif to be true.
Firm Name Certified Tester
Firm Address l)% Cat Tester No.
Gauge # ff/iN 6/
Date last accuracy tested 3 - Z = / /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check:
Refief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight Zar%
osed Tight
Leaked ZED ❑
Opened at
psid
Opened at
nsid
---psid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked Cl
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
nsid
RP-----psid
The above is certif to be true.
Firm Name Certified Tester
Firm Address l)% Cat Tester No.
Gauge # ff/iN 6/
Date last accuracy tested 3 - Z = / /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy