2011_1017 (3)CHECK ONE: /
IRRIGATION y
DOMESTIC
FIRELINE
BACMOW PREVENTION AMEMBLY TEST AND A+iAINTENANCE REPORT
NAME OF PWS: C-o O je e- /
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
O Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer d�a Size z
Model Number dU 71,P, 1 2-T Located At
. B -�
Serial Number Sg / S /
Ten After DC- Closed
Repair Tight
RP
Closed Tight o Opened at Opened at __..D510
p � Sid osid
The above is certified to be true.
Fim Name ,4CTeo1V AaT,,) '510
R
Firm Address Pq 9•" 2 7q-7
Vt%,iK. -M -79)6$
Gauge # or? y1�yI/-8ck,7
Date last accuracy tested Y-/-//
Certified ?ester rrn2�
Cert. Tester No. EL") 6-1-52 Date / /_:_! I
White - Customer's Copy Yellow -v ity copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1 st Check
2nd Check / • 8
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
OpenedAt
osid
Opened at
oSid
_pSid
RP-__ psid
Leaked p
Did not Open ❑
Leaked ❑
Repair.
and
Materials
Used
Ten After DC- Closed
Repair Tight
RP
Closed Tight o Opened at Opened at __..D510
p � Sid osid
The above is certified to be true.
Fim Name ,4CTeo1V AaT,,) '510
R
Firm Address Pq 9•" 2 7q-7
Vt%,iK. -M -79)6$
Gauge # or? y1�yI/-8ck,7
Date last accuracy tested Y-/-//
Certified ?ester rrn2�
Cert. Tester No. EL") 6-1-52 Date / /_:_! I
White - Customer's Copy Yellow -v ity copy Pink - Tester's Copy