2011_0901CHECK ONE:
IRRIGATION DOMESTIC FIRELINE /
BACICFLOW PREVENTION ASSEMBLY TEST AND MALNTENANCE REPORT
NA2vfE OF PWS: Gi y i a OP t t-
PWS I.D. # �lR
LOCATION OF SERVICE: 1 L 22, &-4lam tZek-
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
I Reduced Pressure Principle ❑ Pressure Vacurmm Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer V)A__f'-FS Size
Model Number 77 11106 D A
Serial Number t 1600 "1
u 1
Located At b :j d free --t-
The above is certified to be true.
Firm Name
Certified Testa W, LL' z.,. 1I• a-L "'`"S
Firm Address 109 k S M • LL?-.- Q� - � l 0')- Cat. Tester NAOb003 ?8a- Date
,+ -LL4S 1 3 s,-3�1
Gauge # r7 l 9 H q Cj
Date last accuracy tested 1- -3 / -- 11
White - Customer's Copy Yellow - City Copy 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
DC- Closedof •cl
Closed Tight
Opened at
Opened at
osid
p t- (5
Tight
RP -, psid
Leaked C
Leaked ❑
psid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
t?sid
RP sid
The above is certified to be true.
Firm Name
Certified Testa W, LL' z.,. 1I• a-L "'`"S
Firm Address 109 k S M • LL?-.- Q� - � l 0')- Cat. Tester NAOb003 ?8a- Date
,+ -LL4S 1 3 s,-3�1
Gauge # r7 l 9 H q Cj
Date last accuracy tested 1- -3 / -- 11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy