2010_0209 (4)Feb 15 2010 2:16PM FIRE POWER SYSTEMS (972)641 -5480 P.1
CHECK ONE:
IRRIGATION__ X DOMESTIC FIREMNE
I ACEMOW PREVENTION ABLY 11SI AND MAINTENANCE REPORT
NAME OF PWS:r
PWS I.D. #
LOCATION OF SERVICE: Sao Vrag,0 -F
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 Pre=rre Principle O Pressure Vwmzzn Breaker
5� Double Check Valve ❑ Atmosphere Vacuum Breaker
Maaufacturrs Fe, bGO Size Z 4.
ModcI Number gS-O Located At /,lord-, o � b- fdu.,s
Serial Number D °+ S'l N °l rmes5
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check Relief Valve
Air Iukt
Cluck Valve.
Initial Test DC- Closed Closed Tight sr Opened at
Opened at
'mod
Leaked, p sid
_esid
PTisbt
pis R.P- J asid t 2
Leaked o
Did not Open v
Leaked D
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opp at
Opened at
nsid
Tight o id
_psid
[Repair
RP slid
The above is ceraed to be true.
Firm Name REC. Pew tr S3,s4*r t rrc Certified Testa"'
Firm Address 11 1 Q vg Le.0 br +wZ Cat Testa No. U G 00 '?ZSL Dow -2-1-10
6,1—A Pf ^,t'f +,t41 ix 7Sa rb
Gauge # __ 77 Z 7 7 S"
Date last accuracy tested
White - Customer's Copy YeIIow - City Copy Pink - Tester's Copy