2011_0603CHECK ONE:
IRRIGATION L/
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 13q (,u s 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
Model Number
-5: gc--�o
95-0
Serial Number � / ? 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At �)tTW
The above is certified to be true.
Firm Name
Firm Address 3 C'"D!
Gauge #
31265 r
Certified Tester 5�-V 61U,-OA-�
Cert. Tester No. C30 - Date 3 l
Date last accuracy tested / Z--i C(" -lO
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
losed Tight
Opened at
Opened at
vSid
Tighe
RPsid
Leaked ed ❑
Leaked ❑
pSid
vSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vSid
Repair
Tight ❑
nsid
pSid
RP sid
The above is certified to be true.
Firm Name
Firm Address 3 C'"D!
Gauge #
31265 r
Certified Tester 5�-V 61U,-OA-�
Cert. Tester No. C30 - Date 3 l
Date last accuracy tested / Z--i C(" -lO
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy