2011_1013CHECK ONE:
�-I # >°/- Ii - �2VC,
IRRIGATION DOMESTIC FIRELINE ✓
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 6z / F°710-g
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 ❑ Pressure Vacm= Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Ai
Serial Number ��S % z+
Z-
Located At
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC MW BREAKER
fly
Double Check Valve Assembly
Z-enrt e tt --
Firm
Address
1st Check Z,,,6
I 2nd Check 2, 2-
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened
Opened at
_psid
Tight
Leaked ❑
psid
_psid
RP- _,psid
Leaked ❑
Did not Open C3
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
� sid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm
Nam
A GT o N
fly
—;r -r Certified Tester
Z-enrt e tt --
Firm
Address
2 �?
���'`'jL , Cert Tester No.
BP c'v-s 415Z Date
Gauge # O 7D go �4 8 Z
Date last accuracy tested 9- / - )
White - Customer's Copy Yellow - Clty Copy Pink - Tester's Copy