2011_0901 (2)CHECK ONE.
IRRIGATION DOPdESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 6�- LoepQLi
PWS I.D.
LOCATION OF SERVICE: 1 t ea 6-t-4 4-zL a k.
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
Double Check Valve
Manufacturer W A-+-�S
Model Number o 0-1 m 3
Serial Number
jggq I S
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 3 ly
Located At y..r,1L+ /03 S it- c f.
The above is certified to be true.
Firm Name ®S.S
Firm Address M° Ll4
p4- L- �*S , q 5-13 S
Gauge # a ti C. 4 Lt q
Date last accuracy tested l-3 1- /I
Certified Tester A -
Cert. Tester NAP80e 3 ? 8 J-- Date 9-/-//
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- Closed 1• a
Closed Tight` (
Opened at
Opened at
osid
Tiaht 1�
Leaked ❑
psid
oSid
Pis
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-Si
Repair
Tight ❑
vSid
oSid
RP sid
The above is certified to be true.
Firm Name ®S.S
Firm Address M° Ll4
p4- L- �*S , q 5-13 S
Gauge # a ti C. 4 Lt q
Date last accuracy tested l-3 1- /I
Certified Tester A -
Cert. Tester NAP80e 3 ? 8 J-- Date 9-/-//
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy