2011_0721CHECK ONE:
IRRIGATION L�
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: `36
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 Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
fiManufacturer !g &Z Size 3/ t/
Model Number
Serial Number /f C " [ 6i 'Z,3 ro
Located At 4112, 727 /-
The above is certified to be true.
Firm Name �-
Firm Address 3o C C�
Gauge # co. ;' 47 a -A-4-0
Date last accuracy tested
Certified Tester -'
Ccrt. Tester No. P0Q-")15 Z Date % -Z i-
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
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
psid
Tigh
—Leaked ❑
psid
psid
RP- G psid
Z y
Leaked ❑
Did not Open ❑
Leaked ❑
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 �-
Firm Address 3o C C�
Gauge # co. ;' 47 a -A-4-0
Date last accuracy tested
Certified Tester -'
Ccrt. Tester No. P0Q-")15 Z Date % -Z i-
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy