2011_1017 (6)CHECK ONE:
IRRIGATION DOMESTIC ✓ FIt ELINE
RACMOW PREVENTION ASSEMBLY TEST AND AIAINTENA,NCE REPORT
NAME OF PWS:
PWS LD. ir
LOCATION OF SERVICE: /l(o
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 C3 Pressure Vacuum Breaker
o
Double Check Valve o A=osphere Vacuum Breaker
Manufacturer
Model Number
Serial Number �^
Size47
Located At
The above is certified to be true.
Firm Nam &-Teon/ AaTv 'If
Firm Addrzss Pie 0-7
W.qv -, -rte -75)6$
Gauge # 0!2 o�9D4-,ex
Date last accuracy tested Y-/-//
Cued Tester A'�e'-n.i dk C�
Cent. Tester No. is Pc» 61-5? Date /c3'-/7-. /
White - Customer's Copy Yellowy - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACU[TM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check %, 8
2nd Check 1,
Initial Test
DC- Closed
/Closed Tight 1K
OpenedAt
Opened at
osid
Tight
Leafed ❑
_psid
sid
RP- ____psid
Leaked ❑
Did not Open o
Leaked ❑
Repairb
and
Materials
Used
Test After
R1epair
DC- Closed
Tight ❑
Closed Tight o
Opened at
---_--p sid
Opened at
�osid
RP sid
The above is certified to be true.
Firm Nam &-Teon/ AaTv 'If
Firm Addrzss Pie 0-7
W.qv -, -rte -75)6$
Gauge # 0!2 o�9D4-,ex
Date last accuracy tested Y-/-//
Cued Tester A'�e'-n.i dk C�
Cent. Tester No. is Pc» 61-5? Date /c3'-/7-. /
White - Customer's Copy Yellowy - City Copy Pink - Tester's Copy