2011_1017 (4)CHECK ONE:
IRRIGATION
DOMESTIC
6,I-X
FIRELINE
BAC GLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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 ASSEIvlBLY
o Reduced Pressure Principle
❑ Pressure Vacmmm Breaker
Double Check Valve
o Atmosphere Vacuum Breaker
Manufacturer l�ky
Size
Model Aimnber 0,19/7 / 1 gLL
Located At f �r ��0�`l 6j
Serial Number °
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check 2-'0
Relief halve
Air Inlet
Check Valve
initial Test
DC-Closed
Closed Tight
OpenedAt
Opened at
_______nsid
Tight
Leaked
❑
nsid
oSid
Leaked sid ❑
Did not Open ❑
Leaked ❑
Repair,
and
Materials
Used
Test After DC-Closed Closed Tight
❑ Opened at Opened at _.,_,Dsid
Repair Tight ❑
osid ._ osid
PIP Sid
The above is certified to be true.
Firm Nam CTtyn/ A aTo S f R
Certified Tester
Cert. Tester No. EP,,v - 1-5'7 Date
Firm Address PO Br 7q-7
Gauge #
Date last accuracy tested
White — Customer's Copy Yellow — amity Copy Pink — Tester's Copy