2010_0209 (2)Feb 15 2010 2:1GPM FIRE POWER SYSTEMS (972)641 -5480 P,5
CHECK ONE:
IRRIGATION - DOMESTIC -FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MABqMUNCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: SOO Fr &- .go rf PA r Vy4 H
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
O Reduced Pressure Principle a Pressure Va== Breaker
7( Double Check Valve o Atmosphere Vacuum Breaker
Manufactuaw size
Model Number 06 '7 M 1-4-T Located At t e-t , e � "vi, r a 49,
��$ ire gr�c s rulk� dkul ,
serial Number 12 3
The above is certified to be mu.
Firm Name Flat- Porrtr 5144 -i •s Certi$ed Tester LAmAly S%"AgrM_
Firm Address 1111 Qvt q W tSr i v o- Cart. Tester Na RRW g 2S& Date .2
Gr4�A Vr* rit j-rX 7!r6rO
Gauge #_ 372-7-7
Date last accuracy tested olz - /Q
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check Zad Check
RlW Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight
Ar Opened at
Opened at nsid
1q'SS
Tight Leaked
o Dsid
osid
Leaked o
Did not Open o Leaked o
Repairs
and
Materials
Used
Test After
DC -posed Closed Tight
o Opc2ed at
Opened at e
Rq)air
Tight ❑
--snsid
----,cosid
R d
The above is certified to be mu.
Firm Name Flat- Porrtr 5144 -i •s Certi$ed Tester LAmAly S%"AgrM_
Firm Address 1111 Qvt q W tSr i v o- Cart. Tester Na RRW g 2S& Date .2
Gr4�A Vr* rit j-rX 7!r6rO
Gauge #_ 372-7-7
Date last accuracy tested olz - /Q
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy