2011_0531CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # y
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer Fz `� 6 -y6,0
Model Number d S `�
Serial Number It s'- j52,4r5--
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size _ 6
Located At n;Vj
The above is certified to be true.
Firm Name o 94 OVA
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm Address 3 q,10 (
CL4 '- -P"J
Cert. Tester No POa&-EL
Date �� t
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
-Opened at
Opened at
pSid
Tight
RP -Z6 sid
Leaked ❑
Leaked ❑
f
psid
psid
Did not Open ❑
Leaked 0
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
_ psid
pSid
RP sid
The above is certified to be true.
Firm Name o 94 OVA
e� �
Certified Tester S �
12,1
Firm Address 3 q,10 (
CL4 '- -P"J
Cert. Tester No POa&-EL
Date �� t
Gauge # 13 P10 00,J2 62-
Date last accuracy tested
l Z -19 -1 C
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy