2011_1017 (4)CHECK ONE: /
IRRIGATION DOMESTIC FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAZ%E OF PWS: O 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer 0410, Size 3�`f
Model Number 00-1 y- I 4-rr Located At e -� • g- -�-•.�
Serial Number 7- `� 9 7
The above is caztified to be true.
Firm Name &Ttvn/ A ikT(-' JOE
Fiam Address L' & 7q-7
WAx. -M -7516,9
Gauge # D 17 of >V'i - YZ
Date last accuracy tested Y-/,//
Cect Tester No. EPcw 61-'? Date 10-i I
White - Customer's Copy Yellow - v3ty Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAIXR
Double Check Valve Assembly
Relief V aloe
Air Inlet
Check Valve
1st Check /Y
Znd Check 1. 9
Initial Test
DC- Closed
Tight
/Closed Tight
Leaked ❑
Opened
psid
Opened at
osid
osid
RP- __osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repair,
and
"
Materials
Used
Test After
Reps
DC- Closed
Tight ❑
R p mmmmg�iidd
Closed Tight ❑
Opened at
osid
Opened at
osid
_,.__. sid
The above is caztified to be true.
Firm Name &Ttvn/ A ikT(-' JOE
Fiam Address L' & 7q-7
WAx. -M -7516,9
Gauge # D 17 of >V'i - YZ
Date last accuracy tested Y-/,//
Cect Tester No. EPcw 61-'? Date 10-i I
White - Customer's Copy Yellow - v3ty Copy Pink - Tester's Copy