2011_0524CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # j /' n
LOCATION OF SERVICE: f 7
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.
O used Pressure Principle
Double Check Valve
Manufacturer
S�
Model Number / –7
Serial Number � C— / / 2-/ `
3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Va(ccuuum Breaker
Size
Located At T7 fc_
The above is cerdfied to be true.
Firm NameQAeA Certified Tester r o tJ1P1 1
Firm Address 3 * ( 6 CMG "..� .1A_ Cert. Testa NoffQX ( Date
Gauge # - eAxti
Date last accuracy tested
'3 i 2G S�1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
TighL7
Leaked o
psid
nSid
RP- !s `7 sid,
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
osid
ySid
RP sid
The above is cerdfied to be true.
Firm NameQAeA Certified Tester r o tJ1P1 1
Firm Address 3 * ( 6 CMG "..� .1A_ Cert. Testa NoffQX ( Date
Gauge # - eAxti
Date last accuracy tested
'3 i 2G S�1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy