2011_0106CHECK ONE:
IRRIGATION DOMESTIC FIRELINE !/
BACKFLOW PREVENTION ASS /EM 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS: £ /`
PWS I.D. #
LOCATION OF SERVICE:
J.2o ,5, fV�i / Z 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.
TYPE OF ASSEMBLY
o / Reduced Pressure Principle o Pressure Vacuum Breaker
C� Double Check Valve X kJ1,� o Atmosphere Vacuum Breaker
Manufacturer
Model Number
} -Z Ix- a
35&
Serial Number r0 0"z �a 15! 7
Size
Located At
The above is certified to be true.
Firm Name
Firm Address �A
Gauge # /0OS70 '1y
Date last accuracy tested /- it- d
Certified Tester r
Cert. Testa No. &00xcfq,(P Date. ;.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight )1.5—
Leaked, o
osid
osid
' C-55 S
RP -_psid
Leaked o
S
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address �A
Gauge # /0OS70 '1y
Date last accuracy tested /- it- d
Certified Tester r
Cert. Testa No. &00xcfq,(P Date. ;.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy