2011_0106 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C000e
PWS I.D. #
LOCATION OF SERVICE: <eC=L,-(- lo-k r�C- Cur' 3Z o •S 14) A? I
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 re- 6 c o Size
Model Number L0. Vr3 Located At /��i G'�- tac ✓vt(,4
Serial Number ff oo/ (,v `(
The above is certified to be true.
Firm Name- c S.D! iti urTCertified Tester ' Q141LIA uc
Firm Address ,1 ;17 S, Cent. Testa No. 06P oao`I �`/Date
Gauge # / oa570YO
Date last accuracy tested
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 /.
Leaked ❑
nsid
nsid
'10C, s,s
sid ❑
% $
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ osid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name- c S.D! iti urTCertified Tester ' Q141LIA uc
Firm Address ,1 ;17 S, Cent. Testa No. 06P oao`I �`/Date
Gauge # / oa570YO
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy