2011_0922 (2)CHECK ONE:
IRRIGATION DOMESTIC V-11 FIRE:LINE
BACKFLOW PREVENTION ASSE.M LY TEST AND MAL'YTENANCE REPORT
NAME OF PWS: C t -x 9-,c C—vea e-1 l
PWS I.D.
LOCATION OF SERVICE: I t qL/ 6,, 4-j, e I ec. .
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
V
Double Check Valve
❑ Atmosphere Vacuum Breaker
Manufacturer '\/�.� "�f S
it
Size
Model Number
00-1 M I
Located At VA'I-Y-e- %off � N
- �
Sr de
Serial Number q 4
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check
Relief Valve Air Inlet
Check Valve
Closed Closed Tim t
�
Opened at Opened at
nsid
P
Tight Leaked
RP- I, q psid
❑ psid _ nsid
Leaked ❑
Did not Open ❑
Leaked
haDC-
DC- Closed Closed Tight
❑ Opened at Opened at
nsid
Tight ❑
__psid psid
1
11
RP psid
The above is certified to be true.
Firm Name F a as u^,feO I T4JL, Certified Tester 1 ` , _ -11V
A
Firm Address 01 • c L�f-kOJ- 1 6 d2 Cert. Tester No. 6P000,3 79-2- Date 2-
Gauge #
Date last accuracy tested l - 3 %- I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy