2011_0329CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE v
BACKFLOW PREVE N ASSEMBLY TEST AND MAINTENANCZ REPORT
NAME OF PWS: CIE(, f
PWS I.D. TM
LOCATION OF SERVICE: 2-40 D I V) Dc-- N 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 Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
size��
Located At
The above is ceatified to be true. ,�
Firm Name /9-r = -�'i � 641 A � Certified Tester 4" 3a P Z�L Lev y a�.•z��
Finn Address j'o -9v � 22-7 Cert. Tester No. DaLe
Gauge # 0-7 0.1 a4,? X
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
'ef Valve
Air Inlet
Check Valve
1st Check L -Z
2nd Check- . J
Initial Test
DC- Closed
16osedTisht
Opened -t
Opened at
flsid
Tight
Leaked o
psid
osid
IDidnotOpen
RP- -_psid
Leaked ❑
C3
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
,� psid
Repair
Tight ❑
psid
osid
RP sid
The above is ceatified to be true. ,�
Firm Name /9-r = -�'i � 641 A � Certified Tester 4" 3a P Z�L Lev y a�.•z��
Finn Address j'o -9v � 22-7 Cert. Tester No. DaLe
Gauge # 0-7 0.1 a4,? X
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy