2011_0520CIIECK ONE:
IRRIGATION DOMESTIC '` FIRELINE
13ACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # ' l
LOCATION OF SERVICE: S
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
Manufacturer l kf A—/ l S Size �
Model Number 0 0 Cl' M Z Located At
Serial Number 3V q
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 it Opene4 at Opened at nsid
Ti Z it Leaked � ❑ Z `.L psid esid
RP� _psid
Leaked C Did not Open ❑ Leaked ❑
Reps
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at _p sid
Repair Tight ❑ nsid �psid
RP sid
The above is certified to be true.
Firm Name .01 ACCURACY BACKFLOW Certified Tester
16
Firm Address RICHARDSON, TX 75083 -0416 Cent Tester No. 3�� Date d
Gauge #
Date last accuracy tested Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy