2011_0901CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND IMALNTENANCE REPORT
NAilg OF PWS:
PWS I.D. 9 /,4
LOCATIGN OF SERVICE: . 11 u 4 >-1- Ad ..
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer CIA iS Size
Model Number s Located At V,1-0o /U I-) r-F Id6 Sf, rtf,
Serial Number L51, 9 11 D i
The above is certified to be true.
Firm Name 6 ,55 j7. 2-e-Cn v '*��� -t �c , Certified Tester M. Q -e' -`-`6
Firm Address 10d,166 M 4Lt-et Pd- x Cert. Tester NoAPP003 2 02- Date /
Gauge # -tgyyq
Date last accuracy tested 1 -3 t -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
Phs j
DC- Closed ,. g
Tight
RP -_psid
Closed Tiglft
Leaked ❑
Opened at Opened at
psid _ nsid
DSid
Leaked Cl
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
RP sid
Closed Tight ❑
Opened at Opened at
_ ^nsid nsid
nsid
The above is certified to be true.
Firm Name 6 ,55 j7. 2-e-Cn v '*��� -t �c , Certified Tester M. Q -e' -`-`6
Firm Address 10d,166 M 4Lt-et Pd- x Cert. Tester NoAPP003 2 02- Date /
Gauge # -tgyyq
Date last accuracy tested 1 -3 t -11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy