2011_1005 (7)CIIECI� +ONE:
IRRIGATION
DOMESTIC
FIR E LIN E
BACT�FI.OW PREVENTION ASSEMBLY TEST AND MAIiV'I'ENANC'E REPORT
NAME OF PWS: .i ; c ..
_/
PWS I -D. #
LOCATION OF SERVICE: f` '.' ;� - -�' - .�; �,. ,
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certiYied to he operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressure Principle � Pressure Va�-tr� Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �/i�t --l� '�. Si =e 2 ,
Model IV umber � % �7 % z'I 1 Located At SrzC� �Jor � PY o F nT � `r
serial Number ><I it � t1 �� 1J'la � Id � zs S l d Q
The above is certified to be true.
Firm Namc � �
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester u� %`, , � ,`'� �_��,° �-.
Cent Tester No- '�' -? :� � = ` r � � - � Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaT.'FR
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opined at
Opined at
nsid
Tight t3'
Leaked D
psid
nsid
K.P- nsid
Leaked o
. ��.
Did not Opm D
Leaked D
�P��
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opmcd at
Opined at
nsid
Rrpair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc � �
Firm Address
Gauge #
Date Iast accuracy tested
Certified Tester u� %`, , � ,`'� �_��,° �-.
Cent Tester No- '�' -? :� � = ` r � � - � Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy