2011_0428CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L4
PWS I.D. #
LOCATION OF SERVICE:
UP
i
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.
❑ Reduced Pressure Principle
;D-�bouble Check Valve
Manufacturers 0
Model Number 50
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name ��% ±� Certified Tester
Firm Address �� Cert Tester No. _ Date
Gauge # t- Cea L.0)
Date last accuracy tested C (-IL -1-0
White - Customer's Copy Yellow - City Copy Pink - Tester'a, Copy
s
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
2nd Check
Reliek Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Op t
Opened t
n d
Leaked C]
sid
__:DTight
+�
Leaked
—' y
Did not rn ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name ��% ±� Certified Tester
Firm Address �� Cert Tester No. _ Date
Gauge # t- Cea L.0)
Date last accuracy tested C (-IL -1-0
White - Customer's Copy Yellow - City Copy Pink - Tester'a, Copy
s