2010_0608CHECK ONE:
IRRIGATION I""/J DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE: REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: -� -' t f ✓•
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 Cl Pressure Vacuum Breaker
)' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer A%l-ttf.— Size f`
Model Number 002 144- t Located At %t
Serial Number 6S'VS�4
The above is certified to be true.
Firm Name Ar3=2 A c,_~i', R
Firm Address lay g o 7f7 c.✓
Gauge # O"7 y I . �/ cP
Date last accuracy tested j v 7
Certified Tester X'e ,,
Cat. Testa No. &Po. 6fs'7 Dam 6 - 8 ' 1 u'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
Ist Check -, .6
2nd Check: 2. q
Initial Test
DC- Closed
Closed Tight V
Opened at
Opened at
_ nsid
Tight
Leaked ❑
psid
tysid
RP- ,_�1sid
Leaked 13
❑
Repairs
and
Materials
Used
Test After
DC-Cl o
Closed Tight ❑
Opened at
Opened at
Repair
Tight
osid
o—Sid
RP sid
The above is certified to be true.
Firm Name Ar3=2 A c,_~i', R
Firm Address lay g o 7f7 c.✓
Gauge # O"7 y I . �/ cP
Date last accuracy tested j v 7
Certified Tester X'e ,,
Cat. Testa No. &Po. 6fs'7 Dam 6 - 8 ' 1 u'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy