2011_0901 (3)CHECK ONE:
IRR.IGA`1'ION DOMESTIC V
FIRELINE
BACI- FLOW PREVENTION ASSEMBLY TEST AND IMALNTENANCE REPORT
NAME OF PWS: L d:4 Ce" L.tr
PWS I.D. TM u IA
LOCATION OF SERVICE: 16 '?•a pi 444-o- L Qj -
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
4e Double Check Valve ❑ Atmosphere Vacuum Breaker
N
Manufacturer W 4t FS Size
Model Number 0 01 f 1 Located At N tA!'
Serial Number a y °41 ?
The above is certified to be true.
Firm Name QSS F,k&GvA14 Certified Testa yj,,-- a*'m - m, (2-tues
Firm Address 1O a- 6 S M,Ltt , ► ° 7, Cat. Tester No. A Po Do 7 °7 2,2- Date
P A-L-LAS , 7 5 a-3 S
Gauge # )-1 a H L1 of
Date last accuracy tested k ° 3 1— t
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 t,
Closed Tight 3
Opened at
Opened at
pSid
P'� s
Ti6t ®'
RP -_psid
Leaked ❑
psid
pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
DSid
Repair
Tight ❑
psid
pSid
RP sid
The above is certified to be true.
Firm Name QSS F,k&GvA14 Certified Testa yj,,-- a*'m - m, (2-tues
Firm Address 1O a- 6 S M,Ltt , ► ° 7, Cat. Tester No. A Po Do 7 °7 2,2- Date
P A-L-LAS , 7 5 a-3 S
Gauge # )-1 a H L1 of
Date last accuracy tested k ° 3 1— t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy