2011_1114CHECK ONE:
IRRIGATION DOMESTIC V
FIRELINE
BACiG�LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D.
LOCATION OF SERVICE: 603 Aa Li'l e- rya..
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
N/ Reduced Pressure Principle 0 Pressure Vacuum Breaker
0 Double Check Valve 0 Atmosphere Vacuum Breaker
y;.
Manufacturer \/V a�f -t-S Size
Model Number 0 Ct Located At �41,q iv.o e e,
Serial Number l a 4 0 5 a
The above is certified to be true. yr-S
Firm Name 065
r
Firm Address 0� Cent. Tester No. � 0 3 7 )L Data
X115 �1 I��3 iB
Gauge # a 1 g 4 y g
Date last accuracy tested 1 - i j
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
Pa�s� d
DC- Closed
Tight ,,�1
RP- (o --/ psld
Closed Tight
Leaked 0
Opened at
_psid
Opened at
__,,oSid
flsid
Leaked C
Did not Open 0
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight 0
Opened at
_psid
Opened at
_psid
osid
RP sid
The above is certified to be true. yr-S
Firm Name 065
r
Firm Address 0� Cent. Tester No. � 0 3 7 )L Data
X115 �1 I��3 iB
Gauge # a 1 g 4 y g
Date last accuracy tested 1 - i j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy