2011_1017CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAaaLOW PREVENTION ASSEMBLY TEST AND X4INTENANCE REPORT
NAME OF PWS:
PWS LD.
LOCATION OF SERVICE: 11117
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
mr-*� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer /a Size
Model Number /� °�� Located At
Serial Number 113&51
The above is certified to be true.
Firm Name ACTtolV AaT,, S f R Certified Tester �+►� �j� t Y--
Firm Addrmss Pagri 7 q-7 - Cent. Tester No. EPc'v
Wqv-, T9- '��►�
Gauge # 0!2 01 �V -.- e
Date last accuracy tested
White - Customer's Copy Yellow - Caty 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,, Y
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
OpenedA
nsid
Opened at
nsid
sid
.� sid ❑
�
Did not Open O
Leaked C3
Reps
and
'
Mataials
Used
Test After
Repair
DC- Closed
Tight ❑
RP sid
Closed Tight ❑
Opened at
sid
Opened at
�_,osid
- -psid
The above is certified to be true.
Firm Name ACTtolV AaT,, S f R Certified Tester �+►� �j� t Y--
Firm Addrmss Pagri 7 q-7 - Cent. Tester No. EPc'v
Wqv-, T9- '��►�
Gauge # 0!2 01 �V -.- e
Date last accuracy tested
White - Customer's Copy Yellow - Caty copy Pink - Tester's Copy