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2011_0922CHECK ONE: IRRIGATION DOMESTIC FIRELINE I, BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: �� '� o <' o p p-e-d L PWS I.D. # N %,A LOCATION OF SERVICE: L L )-I q b 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 VV,4 t+ S Model Number (� y .7 rw ?, Serial Number t i S `l O TYPE OF ASSEMBLY o Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size :1 Located At _Y h�ifi h LL 04, N7 The above is certified to be true. Firm REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Q Firm Address %© d- 6 5 In - L61-1 WcO -:1oz 1st Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Tight ❑ RP- _,psid Closed Tight o Leaked Opened at Opened at psid __psid I psid Leaked Did not Open o Leaked o Repairs and Materials Used NS +-n %Ve-� 1b c A z- -K �/. L N e- � Z C.� e c.(t %j 4 L., -e . Test After e DC- Closed Tight 8 sad Closed Tight 1. I f s �� Opened at Opened at psid psid _psid The above is certified to be true. Firm Name 0,5-s f ra J lcQ+ Certified Tester . A Q Firm Address %© d- 6 5 In - L61-1 WcO -:1oz Cert. Tester NQA9022 x-792- Date Gauge # 0- l ci y 9 G Date last accuracy tested-l—,3 1 I l White - Customer's Copy Yellow - City Copy Pink - Tester's Copy