2010_0209 (3)Feb 15 2010 2:16PM FIRE POWER SYSTEMS (972)641 -5480 P.6
CHECK ONE:
IRRIGATION Xe DOMESTIC gERELINE.
BACWLOW PREVEM ION ASSEMLY TEST AND MAMTENANC E REPORT
NAME OF PWS: s L
PWS I.D. #
LOCATION OF SERVICE: S06 rct",Sci- PRA I�waK
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
C3 Reduced Pressure Principle O Pressmc Vacuum Breaker
Double Check Valve C Atmosphere Vacm= Breaker
Manufacwrer Fe.b co Size 2
Model Number SSa
Located At Dirt
of or F tit '
Serial Number _ _ Og S S 3
J JV I rkx S 6:7 ax
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check V save Assembly
Ist Cheek 2nd Cheri:
Relief Valve .
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight
Ar Opened at
Opp at PSW
Ro S
Tight AI( Leaked
RP--b.?---mid
o ,�nsid
_osid —�
t z
Leaked C
Did not Open o L Aked o
Reps
and
Materials
Used
Test Auer
DC- Closed Closed Tight
C Opened at
Opened at nsid
--� --
Reps'
Tight o
sid
sid
RP sid
The above is certified to be true.
Firm Name T'hs. Pewv Sys4c�►s.l�+c. CerzzfiedTesta Q�^""h Sr1r44f%",t,/
Firm Address 1111 >2volis L'vC Curt Testa No. RP60082S'4 Date,
G.r4 --.L 175C '7s`6rb
Gauge # 372 7 7S-
Date last accuracy tested / - 2 S7. /D
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy