2011_1005CfIECiK ONE:
IRRIGATION DOMESTIC FIRELIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAI1�I'I'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is ccrtitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle D Pressure Vac+++**+ Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer ti.I�,. i ti => Size
Model Number %�� fir' �� - L, V` Located At
Serial Number IF 1327
The above is certified to be true.
Firm Name .-��v� c s e-� +�c� f � + e Certified Tester _., .��G, -ti
!� � �-
Firm Address `-%1 `l I 1 "� •�4xc.� 1�.-E Cert. Tester No_ +'> � :.� �: � a : <-� ��`� Date � ;- - "
Gauge # J 2 ads 01 3 0
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Chek1:
Znd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[ O -``
Opened at
Opened at
osid
Tight L3'"
Leaked a
psid
osid
RP- osid
Leaked �
-
Did not Open o
Leaked �
RePa,re
and
Materials
Used
Test Aflrs
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name .-��v� c s e-� +�c� f � + e Certified Tester _., .��G, -ti
!� � �-
Firm Address `-%1 `l I 1 "� •�4xc.� 1�.-E Cert. Tester No_ +'> � :.� �: � a : <-� ��`� Date � ;- - "
Gauge # J 2 ads 01 3 0
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy