2011_0531 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: /7U T2 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.
❑ Reduced Pressure Principle
—� Double Check Valve
Manufacturer
Model Number
FZ,3 (—<;
8 Sv
Serial Number /f C-- /57245--
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size <
Located At S ! C r-(
The above is certified to be true.
Firm Name tol jj v/QA et,-e�-
Firm Address 3 q'®( C1-1 �7Z'----'
Gauge # 6 Po 00, j.5-2-
Date last accuracy tested
Certified Tester C -Y
Cent. Tester No P003'�52- Date �/ 1
I Z- -1 <.( -t 0
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
nsid
Tight
RP -_psid
Leaked ❑
Leaked 13
2�
psid
nsid
Did not Open ❑
Leaked D
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name tol jj v/QA et,-e�-
Firm Address 3 q'®( C1-1 �7Z'----'
Gauge # 6 Po 00, j.5-2-
Date last accuracy tested
Certified Tester C -Y
Cent. Tester No P003'�52- Date �/ 1
I Z- -1 <.( -t 0
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy