2011_1017 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE: /640 �=
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 Vacm= Breaker
1--' Double Check Valve o Atmosphere Vacuum Breaker
Manufaenaer Size Z -
Model Number Ay 5 Located At 8 /w-t
Serial Number
The above is certified to be trace.
Firm Naas E1 Cirvn/ Ay-T,) F�
Firm Address Pg & � 7q-7
W,IK, -M '75)69
Gauge # n t- ye
Date last accuracy tested Y-/,//
Certified Tester /Cr nn e j+. Coof� .r-
Cent Tester No. EPc'1' 6157 Date 10-17- l
White - Customer's Copy Yenow - %,,,,I3ty Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check Z , z-
2nd Check Z. o
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
OpenedAt
Opened at
psid
Tight
Leaked ❑
psid
psid
RP- ___psid
Leaked Cl
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
_____ psid
Opened at
�osid
____-,..osid
R.P sid
The above is certified to be trace.
Firm Naas E1 Cirvn/ Ay-T,) F�
Firm Address Pg & � 7q-7
W,IK, -M '75)69
Gauge # n t- ye
Date last accuracy tested Y-/,//
Certified Tester /Cr nn e j+. Coof� .r-
Cent Tester No. EPc'1' 6157 Date 10-17- l
White - Customer's Copy Yenow - %,,,,I3ty Copy Pink - Tester's Copy