2011_0726CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: I `> f f t- a
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable paraineters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer (,\,� {r� 1►1 S Size 3/� ►
Model Number Located At i UC' i u61� : i'1 CCj f �' (•�' ,~
Serial Number J ��
REDUCED PRESSURE PRINCIPLE ASSEMBLY I 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 ±r Leaked ❑ psid _� sid
Leaked ❑ '� Did not Open o Leaked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight ❑ Opened at Opened at --� sid
Repair Tight ❑ psid �osid
RP sid
The above is certified to be true.
Firm Name A,x ti t' , t >G , c Lam{- I , . Certified Tester
Firm Add= `"l l -3 e
Gauge # ,
Date last accuracy tested �I S
Cert. Tester No.LI' ' %G t' ` f `� l `t Date - Z��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy