2011_0706CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACX'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: w � � f
PWS I.D. ;V
LOCATION OF SERVICE: eiZ/ S" L
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
o Reduced Pressure Principle ❑ Pressure Vacutnn Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer I K114 Jrs Size
Model Number C911-1117 M
Serial Number s-�% 8
Located At /xR t 9,o V- - S , u-#J, Y,, o&- /�� w✓�
S ,44k- _P,�, t e-,k v,,,-
The above is certified to be true.
Firm Name gr wig
Certified Tester .fje:�2nt74 Gavj°�^'
Firm Address %'E 80 S� 7? 7 dt%L' Cent. Tester No. B Pbpa b/ 5'2— Date 7- G - t 1
Gauge # v 7� 9 o V .FF
Date last accuracy tested l?- S, /"
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check /, �a 2nd Check /, S
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed - Closed Tight
Opened At
Opened at
nsid
Ti--& Leaked ❑
psid
osid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed Closed Tight ❑
Opened at
Opened at
� sid
Repair
Tight ❑
_nsid
nsid
RP sid
The above is certified to be true.
Firm Name gr wig
Certified Tester .fje:�2nt74 Gavj°�^'
Firm Address %'E 80 S� 7? 7 dt%L' Cent. Tester No. B Pbpa b/ 5'2— Date 7- G - t 1
Gauge # v 7� 9 o V .FF
Date last accuracy tested l?- S, /"
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy