2011_1017 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEM33LY TEST AND AAEVTENANCE REPORT
NAME OF PWS:
PWS LD.
LOCATION OF SERVICE: I ��
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 Pnn=le ❑ Pressure Vacuin Breaker
VDouble Check Valve ❑ A=osphere Vacuum Breaker
Manufacturer R --t� Size l
Model Number O D-7- YA 1 cP- Located At
Serial Number SLLL / 3
The above is certified to be true.
Firm Name gCTeo / Au-Tn ._ 5
Firm Address Py BP i 7 q3
Wjq y- , -T-NL -75)69
Gauge #
Date last accuracy tested y- /, /
Certified Tester ",111L p� r
Cert.TesterNo.9Povve'1S7 Date I0-I'7- 1
White - Customer's Copy Yellow - C-ity Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check j,
2nd Check A
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Openedat
nsid
Opened at
osid
nsid
RP- ..... •psid
Leaked p
Did not Open ❑
Leaked ❑
Reps
and
Matmials
Used
Test After
Repair
DC- Closed
Tight ❑
gp Sid
Closed Tight ❑
Opened at
osid
Opened at
� osid
___.p sid
The above is certified to be true.
Firm Name gCTeo / Au-Tn ._ 5
Firm Address Py BP i 7 q3
Wjq y- , -T-NL -75)69
Gauge #
Date last accuracy tested y- /, /
Certified Tester ",111L p� r
Cert.TesterNo.9Povve'1S7 Date I0-I'7- 1
White - Customer's Copy Yellow - C-ity Copy Pink - Tester's Copy