2011_0901 (4)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D.
LOCATION OF SERVICE: 10-;, fx i-kf -L- RCP-
The backf7ow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
VDouble Check Valve
Manufacturer l�'� b e0
Model Number 8 s
Serial Number M 'OLD 5 V 0
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size } �2
Located At _ �, Po /� Cl� l �J i6+Lj t {a o-I
The above is certified to be true.
Firm Name Q $ +' to v .'►-{
From Address 10 X 4, 5 M •LL-eo- (4
I 7,-�a3 l?
Gauge # eZ L �/ �► `!
Date last accuracy tested t- 3 j - I
Cert Testa No. 6je Wo 3 -) 8 Date !- / - i I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check:
tad Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
AS5
P
DC- Closed
Tight �
RP- _,psid
Closed TiQ t�
Leaked C
Opened at
psid
Opened at
_osid
osid
Leaked C
Did not Open C
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
psid
Opened at
osid
psid
RP sid
The above is certified to be true.
Firm Name Q $ +' to v .'►-{
From Address 10 X 4, 5 M •LL-eo- (4
I 7,-�a3 l?
Gauge # eZ L �/ �► `!
Date last accuracy tested t- 3 j - I
Cert Testa No. 6je Wo 3 -) 8 Date !- / - i I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy