2011_1017 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACICI'LOW PREVENTION ASSEMBLY TEST AND MAMENANCE REPORT
NAME OF PWS:
PWS LD. i
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 Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size I/V
Model Number c» 7 r .+. Located At ,K- " 41
Serial Number
The above is certified to be five.
Firm Name dC -r jr�n! !} iATc� J �� Certified Tester /CC'rrn�� li r
Firm Address Pg 9., 2 717-7 Cat. Tester No. E Po>v 6152 Date /0- l
WAK. -rte -7 5,E9
Gauge # O `7 0221 ?l p
Date last accuracy tested
White — Customer's Copy Yellow — amity COPY Pink — Tester's COPY
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check 1. Z
DC- Closed
Tight
Closed Tight
Leaked ❑
Openedat
psid
Opened at
osid
n sid
Initial Test
RP- .___psid
Leaked ❑
Did not Open C3
Leaked C3
Repairs
and
Materials
Used
Test After
Repair
DC- Closed Closed Tight ❑ Opened at Opened at _ .—.p sid
Tight C3 �osid _osid
Rp sid
The above is certified to be five.
Firm Name dC -r jr�n! !} iATc� J �� Certified Tester /CC'rrn�� li r
Firm Address Pg 9., 2 717-7 Cat. Tester No. E Po>v 6152 Date /0- l
WAK. -rte -7 5,E9
Gauge # O `7 0221 ?l p
Date last accuracy tested
White — Customer's Copy Yellow — amity COPY Pink — Tester's COPY