2011_1017CHECK ONE:
IRRIGATION V/ DOMESTIC FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE: 1 °
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 Prm=le ❑ Pressure Vacuum Breaker
e Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer �� Size ?-
Model Number
ZOO" Located At & &l sc `i►- Sf
Serial Number
The above is certified to be true.
Firm Name /4��[��/ a ro _ Certified Tester
Firm Address
o,� �,1 Z q"7 Cent. Tester No. E Pc:'z' 6 /--' 2 Date _L2.- i-7- 1
1�IAK, -r�L
Gauge # !_W 7 ,09V' - XZ
Date last accuracy tested
white - customer's Copy
Yellow - " Aty Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check 2. v 2nd Check.
Relief Valve
' Inlet
Check Valve
DC- Closed
Closed Tight
Leaked ❑
OpeaedAt
Opened at
— p sid
_ nsid
Initial Test
Tight
_____osid
Rp'-- --psid
Leaked o
Did not Open o
Leased ❑
Repairs
,
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
o sid
�� sid
Repair
Tighe ❑
o_,ysid
gp sid
The above is certified to be true.
Firm Name /4��[��/ a ro _ Certified Tester
Firm Address
o,� �,1 Z q"7 Cent. Tester No. E Pc:'z' 6 /--' 2 Date _L2.- i-7- 1
1�IAK, -r�L
Gauge # !_W 7 ,09V' - XZ
Date last accuracy tested
white - customer's Copy
Yellow - " Aty Copy Pink - Tester's Copy