2011_0105 (4)CHECK ONE=
IRRIGATION !` llOMESTIC
FIRELiNE
BACKFLOW PREVENTION ASSEMBLY "PEST AND MA.IN'TENANCE REPORT ,, -g
NAME OF PWS:
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PWS I.D. # , � ,,�. S;x `,,;• = a �' E
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LOCATION OF SERVICE: zr <.�_ / St�-� t /U _ t y 1p•�i -< ,uf_
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 ASSEIv1BLY
� Reduced Pressure Principle � Pressure Vacuum Breaker
�` Double Check Valve � Ammosphere•Vacuum Breaker -- __ -- -
Manufacturer � •
e �c Size
Model Number %Fi � C_ Located At _ -� Nl �� � r ! � r i : c .�+ ; =�, ._
Serial Number H ! °� � t
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY" I PRESSURE VACUUM BRF' ��'F'R
Double Check Valve Assembly
1st Cher1: Znd Check Relief Valve ?sir Inlet Check Valve
Initial Test C- Closed - Crased Ti�t7 �1 Opened at Opened at nsid
- Ti�ht� 0 Leaked � psid nsid
RP- -� �osid � . �d
I- eaiced � Did not Open o Leziiced o
Rcp airs
and
Matcnals
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 � t ��=- Certified Tester
Firm Address � Cert. Tester No. Date
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Gauge # �' ! /� ?f_,��, ter`' '1
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Date last accuracy tested � -��� - J�
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy