2011_1017CHECK ONE:
IRRIGATION DOMESTIC FIRELINE y
BAMLOW PREVENTION ASSEMBLY TEST AND AL4INTENANCE REPORT
NAME OF PWS:
PWS LD. #
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 ❑ Pressure Vacuurn Breaker
12✓ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
1-L�k4 Size L
Model Number 7 ° 4 dx-y-&- Located At Y � r 01� 5-txj �
Serial Number
The above is certified to be true.
Firm Name 6C -T10n1 4411-2 '3 f r2
Firm Address PL; & � 7q-7---
-_
Wqk, -TV- 'IS)h$
Garage # 017011y,� gZ
Date last accuracy tested Y-/-//
Certified Tester
Cent Tester No. M'" 6I 5 *7 Date Imo- I7,i1
White - Customer's Copy Yellow - vity Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check halve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 1.2-
2nd Check Z
Initial Test
DC- Closed
Tight IV
Closed Tight
Leaked ❑
Openedat
sid
Opened at
osid
_psid
RP-_ nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
M sid
Closed Tight o
Opened at
sid
Opened at
asid
sid
The above is certified to be true.
Firm Name 6C -T10n1 4411-2 '3 f r2
Firm Address PL; & � 7q-7---
-_
Wqk, -TV- 'IS)h$
Garage # 017011y,� gZ
Date last accuracy tested Y-/-//
Certified Tester
Cent Tester No. M'" 6I 5 *7 Date Imo- I7,i1
White - Customer's Copy Yellow - vity Copy Pink - Tester's Copy