2011_0606CHECK ONE:
IRRIGATION-
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 0-i) -r
PWS I.D. #
LOCATION OF SERVICE: 7 I ( � M
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.
❑ Reduced Pressure Principle
PG Double Check Valve
Manufacturer r---e-6 f-o
Model Number �- 15�
Serial Number f l e a ( - -O
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size -j�
Located At fA 2 l w' Az,
The above is certified to be true.
Firm Name m Area TRACY 9ACKFLOW
P.O. BOX 830416
Firm Address RICHARDSON, TX 75093 -0416
Gauge # D yuzel 77
Date last accuracy tested 7 Z / a
Certified Tester 11
Cert. Tester No. 3 `'I 1 I Date
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:
Relief Valve
Air Inlet
Check Valve
Initial Test
P� S
DC- Closed ,.
Tight X
RP -_psid
Closed Tigh
Leaked ❑
Opened at
�psid
Opened at
_nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
_psid
Repair
Tight E3
nsid
nsid
RP psid
The above is certified to be true.
Firm Name m Area TRACY 9ACKFLOW
P.O. BOX 830416
Firm Address RICHARDSON, TX 75093 -0416
Gauge # D yuzel 77
Date last accuracy tested 7 Z / a
Certified Tester 11
Cert. Tester No. 3 `'I 1 I Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy