2011_0329 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAYNTENANCZ REPORT
NAME OF PWS:
PWS LD.
LOCATION OF SERVICE: Z q-v %) v r O rC
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 o Atmosphere Vacuum Breaker
Manufacturer
Model Number o °,? �JA I
Serial Nurnber A 266-4&
SIZe
Located At
The above is certified to be true.
Firm Name )4 c_7t_^- 74 wt �
Firm .Address E0 904 727 2
¢auge # o —, v e) q8 B
Date last accuracy tested Y ; IV
Certified Testae � �� �� 4
i
Cert, Tester No.
White - Customer's Copy YeDow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ief Valve
Air Inlet
Check Valve
ist Check Z 2nd Check /
Closed Closed Tight
Opened At
Opened at
nsid
Tight Leaked 7
_,nsid
osid
RP- __,psid
Leaked ❑
Did not Open ❑
Leaked ❑
LDC-
Test After
DC- Closed Closed Tight D
Opened at
Opened at
oSid
Repair
Tight ❑
.opsid
_nSid
RP sid
The above is certified to be true.
Firm Name )4 c_7t_^- 74 wt �
Firm .Address E0 904 727 2
¢auge # o —, v e) q8 B
Date last accuracy tested Y ; IV
Certified Testae � �� �� 4
i
Cert, Tester No.
White - Customer's Copy YeDow - City Copy Pink - Tester's Copy