2011_0901 (2)CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L�-
PWS I.D. # wIA
LOCATION OF SERVICE: I /'V `l A,/ Ad-
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
ID Reduced Pressure Principle Cl Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer f, C.G Size
Model Number 5 Located At
Serial Number /-1 / 1 1� r
The above is certified to be true.
Firm Name
Firm Address / G 1 /11 ' L 1 e7,
Gauge #
Date last accuracy tested -4 - //
Certified Tester % %`��'`'�'
Cent. Testa No Me 2, Date
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
Prt6S
DC- Closed 5
Tight
RP -_psid
Closed Tight
Leaked ❑
Opened at
psid
Opened at
_ ^osid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
p sid
RP sid
The above is certified to be true.
Firm Name
Firm Address / G 1 /11 ' L 1 e7,
Gauge #
Date last accuracy tested -4 - //
Certified Tester % %`��'`'�'
Cent. Testa No Me 2, Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy