2011_1017 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE '!
BACMIOW PREVENTION ASSEMBLY TEST AND X4DW4ANCE REPORT
NAME OF PWS
PWS LD. #
LOCATION OF SERVICE: a /o
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
o Reduced Pressure Principle ❑ Pressure Vacuum Breaker
iDouble Check Valve ❑ Atmosphere Vacuum Breaker
Manufacnaer A °1 Size
Model Number Located At
Serial Number q 9z- 3 3
The above is certified to be true.
Firm Name , &1794Z &-12 Ceedfied ?ester a nail %-
Firm Address Pv 9,o 7q-7 Cent. Tester No. EPc'v G 1S7 Date /0-
Gauge # Ori fl91)'k9?
Date last accuracy tested
White - Customer's Copy Yellow - amity Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check / 2
2nd Check /,
DC- Closed
Tight
Closed Tight
Leaked ❑
OpenedA
psid
Opened at
osid
osid
Initial Test
RP- _____Psid
Leaked ❑
Did not Open ❑
Leaked t7
Repairs
and
Materials
Used
Test After
Reps
DC- Closed
Tight ❑
R.p sid
Closed Tight ❑
Opened at
_,osid
Opened at
,i osid
_osid
The above is certified to be true.
Firm Name , &1794Z &-12 Ceedfied ?ester a nail %-
Firm Address Pv 9,o 7q-7 Cent. Tester No. EPc'v G 1S7 Date /0-
Gauge # Ori fl91)'k9?
Date last accuracy tested
White - Customer's Copy Yellow - amity Copy Pink - Tester's Copy