2011_1129 (4)CHECK ONE;
IRRIGATION
DOMESTIC
FIRELINE
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L `l 4' F (c
PWS I.D. #
LOCATION OF SERVICE: -L 3 5 F/� rQ��
The backflo%� prey ention assentbiy detailed beloNti has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Q Reduced Pressure Principle O Pressure Vacuum Breaker
PDouble Check Valve c Atmosphere Vacuum Breaker
:Manufacturer WCr S Size 31`i
Model Number 00'7 Located At i1 a— v c i C 5 %12c
Serial Number 5 X151.1
The above is certified to be true.
Firm Name A L -r, (—, -r
Firm Address PC %; x 7 5 '7
wc- xC,YN cG,w
Gauge # 3-� g S I g
Date last accuracy tested 5-///
Certified Testa CJa" n e— ICJ e- vi i4 t-1,
Cat Testa No. ,HoLx� iqJ Dace // N
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSUIRE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Nett
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight /, g C
RP- _-psid
Closed Tight W
Leaked �,U O
Opened at
osid
Opened at
osid
osid
Leaked O
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight O
RP sid
Closed Tight O
Opened at
osid
Opened at
_ osid
osid
The above is certified to be true.
Firm Name A L -r, (—, -r
Firm Address PC %; x 7 5 '7
wc- xC,YN cG,w
Gauge # 3-� g S I g
Date last accuracy tested 5-///
Certified Testa CJa" n e— ICJ e- vi i4 t-1,
Cat Testa No. ,HoLx� iqJ Dace // N
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy