2010_0209 (8)Feb 15 2010 2:16PM FIRE POWER SYSTEMS (972)641 -5480 p.2
CHECK ONE:
IRRIGATION DOMESTIC FIAELINL X.
BACIYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: __ C i a�- C• pit ( I
PWS I.D. #
LOCATION OF SERVICE: _ So0 Frtwrr4~ Pxr L. ,= ._
The backflaw 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 Principle 0 Pressure V acxnau Breaker -
Sr Double Check Valve 0 Atmosphere Vacuum Breaker
Maanfacturer ( &*$ Size [6
Model Nmnbeer -7-7q 64F -&.4 Located At No4 et- 6.1(diva a F. 6, G
Serial Number I o S 11.7 o b 8
Date last accuracy tested _ / - �S" • O
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY 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
esid
Tight Leaded
o _Y sid __psid
PAS
'� 2 y
Did not Open a
Lashed o
Repairs
and
Materials
Used
Test A$cr
DC- Closed Closed fight
o Opened at Openod at
Repair
Tigk 0
nsid esid
1tP 'd
The above is
certified to be true.
Firm Name Elh&
Pat--w S u sla-i r. %v t Certified Testa �ja&,:j
FnmAddn=
11'71 l7oj4lac b'l' -It Cat. Testa No. gAeoofzno Daft -2-
A Pro,ef L �7y W -tic"o
Gauge # _ 27Z-7-7S'
Date last accuracy tested _ / - �S" • O
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy