2011_0629 (2)CIIECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �.r�� �� �-o �L1.Ii� % 7r d 1 l a
PWS I.D. #
11z 46 z 5/5()
LOCATION OF SERVICE: G d , / / -c /e
The backflow prevention assembly detailed below has been tested and amtained aTrequired by TCEQ
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
Double Check Valve
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Manufacturer bbi 5' Size
Model Number q -5�O A-7- ` 6 C- Located At
Serial Number WFZ,5 4<4-0
�/Z--
lew
The above is certified to be true.
wrkp Bxkfluw & Plumbing
Firm Name
Firm Address Mes. i . r
2 / 4 �''7 Z
Gauge # 3 0 O
Date last accuracy tested - 7
4 ".
Certified Tester �l 5
W1 01
Cert. Tester 96 & Date
White - Yellow N Pink -
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
1 Air Inlet
Check Valve
InirW Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
fs
/I
Tight
RP -_psid
Leaked ❑
Leaked ❑
l `
osid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_ nsid
RP sid
The above is certified to be true.
wrkp Bxkfluw & Plumbing
Firm Name
Firm Address Mes. i . r
2 / 4 �''7 Z
Gauge # 3 0 O
Date last accuracy tested - 7
4 ".
Certified Tester �l 5
W1 01
Cert. Tester 96 & Date
White - Yellow N Pink -