2011_0329 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKPLOW PREVENTION ASSEMBLY TEST AND MAINTENANC" REPORT
NAME OF
PWS LD. rr
LOCATION OF SERVICE:
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 O Pressure Vacutan Breaker
Double Check Valve Cl Atmosphere Vacuum Breaker
r�
Manufacturer JA z,� Size _.._.�_
Model Number -7 4 d 'L Located At
Serial Number / /yJz'l
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check .
2nd Check- Reef naive Air Inlet Check Valve
Initial Test
DC- Closed
Closed Tight Opeaed.At Opened at nSid
Tight
Leafed ❑ _._ -psid nsid
RP ------ psid
Leaked ❑
Did not Open o Leaked ❑
L
DC- Closed
Closed Tight ❑ Opened at Opened at �_psid
Tight ❑
nsid �osid
RP sid
The above is certified to be true.
Firm Na= A
c- Tvor) A,
Certified Testa
Firm .Address
Ez�-. Z :;� 7c/
7 cat Testa No. 13 y &-mate 3
Qauge # o--?oej(, `2g
Date last accuracy tested o
White - Customer's Copy Yellow - Cfty Copy Pink - Tester's Copy