2011_0520 (2)CIIECK ONE:
IRRIGATION DOMESTIC )'61
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
?2 � L =,Ao., 1z 1 j5o
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 Cl Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size �f A—
Model Number D Q Located At J44 L% AD
Serial Number 3 63 2- 3
The above is certified to be true.
Firm Name m . 43JtACy 9A"JL0W
P.O. BOX 630410
Firm Address RICHARDSON. TX 750A3 =04 1 6
972 -699 -7156
Gauge # f) V y Z of 7 2
Date last accuracy tested
Certified Tester sJi4�i� I"l� r
Cert. Tester No. ; Date ?—D - t 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
Tight �Q
RP -sid
Closed Tight �&
Leaked .-7. z ❑
Opened at
44.,6 sid
Opened at
nsid
_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
L t After
air
DC- Closed
Tight C
Closed Tight o
Opened at
___nsid
Opened at
_ osid
nsid
RP sid
The above is certified to be true.
Firm Name m . 43JtACy 9A"JL0W
P.O. BOX 630410
Firm Address RICHARDSON. TX 750A3 =04 1 6
972 -699 -7156
Gauge # f) V y Z of 7 2
Date last accuracy tested
Certified Tester sJi4�i� I"l� r
Cert. Tester No. ; Date ?—D - t I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy