2011_0106 (5)CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CAD,, e �l
PWS I.D. #
LOCATION OF SERVICE: --5r^c-. -•t c- � Y'� C �� y, S 1 Nu�y l 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
❑ r Reduced Pressure Principle ❑ Pressure Vacuum Breaker
p/ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer % tx- o Size
Model Number ° �e -U� ox
�J � Located At T � �i
Serial Number
The above is certified to be true.
Firm Name Certified Tester
//,Y) _
Firm Address .4" caw V, %e Cent. Tester No. :29 07,11oV Date - <�
Gauge # �J?J5 /y
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
psid
Tight
Leaked ❑
psid
psid
5�
RP -_psid
Leaked ❑
1,3
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name Certified Tester
//,Y) _
Firm Address .4" caw V, %e Cent. Tester No. :29 07,11oV Date - <�
Gauge # �J?J5 /y
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy