2011_1017 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. N
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 Vacurmi Breaker
R✓ Double Check Valve o A=osphere Vacuum Breaker
a� Size
Manufacturer .. //
Model Number -707 X c- a w— Located At N' L , v n .. r �{� PK, )6
Serial Number ll q-4! o 2--
The above is certified to be true.
Firm Name fI C�'t vn/ A a.Tc� � Certified Tester ran e� % C r
Firm Address - fe &'' 7 q`_ Cent Tester No. EPc'v G /-" 2 Data /0-'
WAk , -M
Gauge # 07 o(1V'� -9Z c�
Date last accuracy tested
White - Customer's Copy Yellow - "ity copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check ,'V
2nd Check 1.0
DC- Closed
Tight
Closed Tight e
Leaked ❑
Opened - t
psid
Opened at
psid
psid
Initial Test
Le --mod
Leak-ad
Did not Open C3
Leaked ❑
Repairs
and
'
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Rp sid
CIosed Tight o
Opened at
vsid
Opened at
_psid
The above is certified to be true.
Firm Name fI C�'t vn/ A a.Tc� � Certified Tester ran e� % C r
Firm Address - fe &'' 7 q`_ Cent Tester No. EPc'v G /-" 2 Data /0-'
WAk , -M
Gauge # 07 o(1V'� -9Z c�
Date last accuracy tested
White - Customer's Copy Yellow - "ity copy Pink - Tester's Copy