2011_0105 (3)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NA)\� OF PWS:
PWS LD- #
LOCATION OF SERVICE: t r-s�r. ` � �`.� . ! � +s� c f�, �-t t-. .
"f he 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
D Reduced Pressure Principle O Pressure Vacuum Breaker
O Double Check Valve o Atmosphere Vacuum Breaker
�.
Manufacturer L�� • ,- l � Size !
Model Number � ,'� l� . Located At A i� - � ✓�'l� . ,� L. ,.. e
Serial Number ;'-� ��7 f � F5 �
REDUCED PRESSURE PRINCIPLE ASSE1�iBLY PRESSURE VACiTCTM SRE.4h'ER
Double Check Valve Assembly
1st Chek1: 2nd Checl:
Relief Valve Air Inlet
Check Valve
Initial Test DC- Closed
Closed Tight �
Opened at Opened at
nsid
Tight � , �, �
Leaked o
psid nsid
RP- DSld
Leaked D
Did not Open o
Leaked D
Rcp airs
and
Materials
Used
Test After DC- Closed
Closed Tight o
Opened at Opened at
nsid
Repair Tight o
nsid nsid
RP sid
The above is certified to be true.
Firm Name � - � �` Certified Tester
Firm Address Cezt Tester No.
Gauge # / _,- -;Eti .. -�. _x,
Date Iast accuracy tested �� -"-' -
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
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