2011_0315CHECK ONE:
IRRIGATION )O DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. i!
LOCATION OF SERVICE: �` ��/'�BI@��} ` .
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
xDouble Check Valve ❑ AunospherejVacuum Breaker
Manufacturer (--V Size 3`1i 1'
Model Number 75-b Located At Fizooi uR-if-U oar
Serial Number dco(po44
The above is certified to be true. dd
Firm Name �2vS-f /�l!•C f flow Certified Tester -
Firm Address 3 i 13 lee 4iv o k gr - Witj Cert. Tester No. 56,01 Date - �S
Tx -70c- /
Gauge # �3
Date last accuracy tested )-- f- //
White - Customer's Copy
9/4, 5.40ppnzL
Yellow - City Copy
h1x-.
Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
s�
DC- Closed
Tight
R = 3 osid
Leaked ❑
Closed Tight
Leaked C3
Opened at
psid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true. dd
Firm Name �2vS-f /�l!•C f flow Certified Tester -
Firm Address 3 i 13 lee 4iv o k gr - Witj Cert. Tester No. 56,01 Date - �S
Tx -70c- /
Gauge # �3
Date last accuracy tested )-- f- //
White - Customer's Copy
9/4, 5.40ppnzL
Yellow - City Copy
h1x-.
Pink - Tester's Copy