2011_0106 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE !/
BACK]FLOW PREVENTION ASS E/M 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CO-44 /
e `r
PWS I.D. #
LOCATION OF SERVICE: �t'c µ, ��eK `�i2--6.qC (,e.,
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
❑ / Reduced Pressure Principle
GX Double Check Valve
Manufacturer r-e be j
Model Number �S6
Serial Number
Size
ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
c
Located At 1.�� V� �y (`�' �; �° rz ►,c_c.
The above is certified to//be true.
Firm Name 1 -gf- off- T-/'� Certified Tester f'
Firm Address / H) S Ce�Ynr ��sC Cert. Tester No. 301 :6 V' Date
() , 1tc-i v,✓1
Gauge # /
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:
I 2nd Check:
Relief Valve
1 Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight e
Opened at
Opened at
psid
Tight,?. Z
Leaked ❑
psid
vsid
f�
ti `'SS
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to//be true.
Firm Name 1 -gf- off- T-/'� Certified Tester f'
Firm Address / H) S Ce�Ynr ��sC Cert. Tester No. 301 :6 V' Date
() , 1tc-i v,✓1
Gauge # /
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy