2011_0815CHECK ONE:
IRRIGATION
' \ V
DOMESTI J
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: i Of Co Gb P `
PWS I.D.
LOCATION OF SERVICE: 6rci 51 D+,� -1 AO S 60D W Ic", 0 0ZbO
TX '7 S o 1 G1
The backflow prevention assembly detailed below has been tes ed and rfiaintamed as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacurmm Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
sp l
aer
Manufacturer
WCEAO, Size I
Model Number 0011') Z Located At - CO2A
Serial Number 4y- 60 r �tr W aivr
The above is certified to be true.
Wright BacF m & PLBG
Firm Name
Firm Address TX 75150
x 4 1517 Z 3HID
Certified Tester R QA n e kf
Cent. Tester No. �Q 75QDate
Gauge # l A 'S 4) Z 3 1Al ct k- -�S T K- 9 g E
Date last accuracy tested "j - 7 /
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
Poi�%
✓�,
DC- Closed
Tight ,e'
RP- Mt 0 Sid
Leaked ❑
Closed Tight
Leaked ❑
% "�
Opened at
sid
Opened at
oSid
Did not Open o
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
p sid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Wright BacF m & PLBG
Firm Name
Firm Address TX 75150
x 4 1517 Z 3HID
Certified Tester R QA n e kf
Cent. Tester No. �Q 75QDate
Gauge # l A 'S 4) Z 3 1Al ct k- -�S T K- 9 g E
Date last accuracy tested "j - 7 /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy