2011_1017 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC MOW PREVENTION ASSEMBLY TEST AND A CE REPORT
NANE 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 Prmcwle ❑ Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer —gS£_ _._...- Size -
Model Number =� - Located At ��a
Serial Number 1 Ry 3 v
REDUCED PRESSURE PRINCIPLE ASSEMBLY 1 PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check Z -
Inirial Test DC- Closed
Tight
Rp-_ psid
Leaked _ ❑
Ptepairs
and
Materials
Used
Test After DC- Closed
Repair Tight
RP
2nd Check Z, a I Relief Valve ( Air Inlet ( Check Valve
Closed Tight Opened Opened at � sid
Leaked ❑ nsid �sid
o I Closed Tight ❑ I Opened at
�osid
The above is certified to be true.
Firm Name _ &TjolV A uL
Firm Address PO A- !� Z y-7
VVAK, -- '75,61;
Gauge # 07 00YV11-8P
Date last accuracy tested y - / - / I
Did not Open C3 Leaked
Opened at psid
______osid
Certified Tester b mire k C.toe-,2-` --
Cat. Testa No. EPc''v 61.5'7 Date 10-1q- I
White - Customer's Copy
Yellow - %ity Copy Pink - Tester's Copy