2011_1017 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE l/
BACMOW PREVENTION ASSEMBLY TEST AND KADMENANCE REPORT
NAME OF PWS:
PWS I.D. # -
LOCATION OF SERVICE: `l 0 - --
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 &4'4t- Size 114-
Model Number PO 7 ' T Located At P/ �� cor-►- v �.
Serial Number 89&
The above is certified to be true.
Firm Name d C T-1 /V AU—T,) - Certified Tester )i—�-e ran dk ' r
Firm Address ��' &-'2 Zq-7 Cen. Testa No. EPc yr 6IS'7 Date / 0 — i
Gauge # D 17 fl'' v lk- ,f
Date last accuracy tested
White - Customer's Copy Yellow - City COPY Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
:fir Inlet
Check Valve
1st Check 1, 6,
2nd Check Z • 2
DC- Closed
Tight
Closed Tight e(
Leaked ❑
OpenedAt
osid
Opened at
nsid
sid
Initial Test
RP-_ nsid
Leaked ❑
Did not Open ❑
Leaked ❑
F,epairs
and
'
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
gp sid
Closed Tight ❑
Opened at
sid
Opened at
sid
____,psid
The above is certified to be true.
Firm Name d C T-1 /V AU—T,) - Certified Tester )i—�-e ran dk ' r
Firm Address ��' &-'2 Zq-7 Cen. Testa No. EPc yr 6IS'7 Date / 0 — i
Gauge # D 17 fl'' v lk- ,f
Date last accuracy tested
White - Customer's Copy Yellow - City COPY Pink - Tester's Copy