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2011_0815 (2)
CHECK ONE: IRRIGATION DOMESTIC FIRELINE BAC FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: t Of LQ S. d I Cz -�f `, �F�l PWS I.D. # -15 LOCATION OF SERVICE: 2L , S E, td ttZo c, �� '7�0f9 �7L.3g3- The backflow prevention assembly detailed below has been tested a d mainilnied as required by TCEQ 7 t 7U regulations and is certified to be operating within acceptable parameters. / TYPE OF ASSEMBLY �S Reduced Pressure Principle Cl Pressure Vacuum Breaker ❑ Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer ( Size h 11 Model Number 9 vii 7— Serial Number Located At WetX1, � . Jj �5— D S951�, The above is certified to be true. Firm Name Might DacMow & PM Certified Tester RO dki t (V k 1 ht Firm Address • 7X 761W Cert° Tester Nog R ®FMIo Date i 5 ? Z 34DD Gauge # 3 g -3 W ATrS 7-k y 9 E Date last accuracy tested - — l 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 Checl: Relief Valve Air Inlet Check Valve ual Test DC- Closed Closed Tight Opened at Opened at psid Tight A- fV' Leaked C) r psid osid RP- psid © 0 D ° Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and Materials Used Test Afler DC- Closed Closed Tight ❑ Opened at Opened at _- psid Repair Tight ❑ psid psid RP psid The above is certified to be true. Firm Name Might DacMow & PM Certified Tester RO dki t (V k 1 ht Firm Address • 7X 761W Cert° Tester Nog R ®FMIo Date i 5 ? Z 34DD Gauge # 3 g -3 W ATrS 7-k y 9 E Date last accuracy tested - — l White - Customer's Copy Yellow - City Copy Pink - Tester's Copy