2011_0106 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: c2402t;, 6
PWS I.D. # /'
LOCATION OF SERVICE:, 11OL -iP (.-I-je, C 329 S, tka
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
v Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer / Size �/V
Model Number 9 YE _ Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address .D -P, x, V, le '
Gauge # /J
Date last accuracy tested
Certified Tester _ (Ir r-
Cert. Testa No. 900WA&L Date /
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
psid
Tight 13 N
Leaked ❑
psid
osid
R ------psid
%- Z
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
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
Firm Address .D -P, x, V, le '
Gauge # /J
Date last accuracy tested
Certified Tester _ (Ir r-
Cert. Testa No. 900WA&L Date /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy