2011_0329 (2)CHECK ONE:
IRRIGATION DOMESTIC t1 FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCZ REPORT
NAME OF PWS:
PWS I.D.
LOCATION OF SERVICE: 2- 4 0 L� i y< A,-- J
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
CV Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer Size
Model Number U 0 9 Y11s I
Serial Number 6 2-b9 'I-?,
Z
Located At zl'� Lc-'D .SA'k,4
The above is certified to be true.
c
Firm Name e r i vrJ �°' ` f ` Certified Tester
Firm Address P° u U Ces t. Testes No. R P ,,-" r� %Dgo
Gauge # o-? v 9 r- 4 Y
Date last accuracy tested (0
White - Customer's Copy YeHow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check /, (a
I 2nd Check-/X
Initial Tess
DC- Closed
Closed Tight
ened,A
Opened at
vsid
Tilt
Leaked C3
!Op
_nsid
osid
RP -- psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
-
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_,_ -- sid
Repair
Tight ❑
p sid
oSid
RP sid
The above is certified to be true.
c
Firm Name e r i vrJ �°' ` f ` Certified Tester
Firm Address P° u U Ces t. Testes No. R P ,,-" r� %Dgo
Gauge # o-? v 9 r- 4 Y
Date last accuracy tested (0
White - Customer's Copy YeHow - City Copy Pink - Tester's Copy