2011_1129 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MADCrENANCE REPORT
NAME OF PWS: L r -T\ It 42L f c (, i2 i2 l
PWS I.D. #
LOCATION OF SERVICE: _19 r� r- -rk r
The backtlox� prey ention assembly detailed behm has been tested ar-id maintained as required by TCEQ
regulations and is ccrtiled to be operating within acceptable parameters.
TYPE OF ASSEMBLY
G Reduced Pressure Principle Pressure Vacuum Breaker
Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer k -e he" Size
Model Number Located At 1 '�� v ' 4) �'c�i �IJ cr ►�'le r
Serial Number
The above is certified to be true. ve 5
Firm Name A e T(v.J Cv -c-
Firm Address k &,c `7 5 '7
WCxCV%ceh
Gauge # _ 3>j yS i )
Date last accuracy tested )—Z I/
Certified Tester N W r- y A e W d?, i u e
Cert Tester No. Poo - < < J r _ Due j11Jcj111
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAIaR
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Ininal Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
Tight 10
RP- J-0--psid
Leaked d 0 :
osid
nsid
Leaked ❑
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight o
nsid
osid
RP sid
The above is certified to be true. ve 5
Firm Name A e T(v.J Cv -c-
Firm Address k &,c `7 5 '7
WCxCV%ceh
Gauge # _ 3>j yS i )
Date last accuracy tested )—Z I/
Certified Tester N W r- y A e W d?, i u e
Cert Tester No. Poo - < < J r _ Due j11Jcj111
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy