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2011_0105CIIECIf ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: k _ PWS I -D. # LOCATION OF SERVICE: 4�� 1 A) . 1� `��_ P�. yi -- � ��,,,,,� ._.t" i� -,�,y c The backtlow 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 Rrduced Pressure Principle a Pressure Vacuum Breaker � Double Check Valve � Atmosphere Vacuum Breaker Manufacturer Size f- f Modei N�ber Located AL '�- � �- � � ='- �r -� / 1 " ": , r L-- ,.mac Serial Number Gauge # Date last accuracy tested White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BTZF'A�'F'R Double Check Valve Assembly 1st Check 2nd Cheri: Relief Valve Air Inlet Check Valve Initial Test DC- Closed _Tigizt © CI"oseci Tight �eaiced C3 Opened at O psid Opened at osid acid � RP- osid Leaked D Did aot Open o Leaked o �P� and Materials Used Test After DC- Closed Closed Tight o Opened at Opined at osid Repair Tight � osid osid RP sid The above is certified to be true - Firm Name Certified Tester - - - 9 , : � - , ; - -- Firm Address Cat Tester No- a ',''r -- f. /:'�, � Date i Gauge # Date last accuracy tested White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy