2011_0401CIIECIi ONE=
IRRIGATION DOMESTIC FIRELINE
BACT�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: '" x' - ,�
The 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
Reduced Pressure Principle � Pressure Vacua Breaker
D Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �A� S Size
Model Number O U�f �n °� Located At /Pi Sc'� /ri00n't
Serial Number � 0'02 �� �
The above is certified to be true. �/ea
Firm Name ��, 5�i2�fr•••+ -rd1 �,. Certified Tester �. L" „� � _ .. '”
-t•
�' s , ,. ,.
Firm Address �DaZ �a✓l /�• 1 -lC�[- � - Cctt Tester No(,'�"t?f�c� � % �� Date �' / ! .> %%
gauge # <� (� L/ L/
Date last accuracy tested f <'� r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRRaKFR
Double Check Valve Assembly
1st Chekl:
2nd Chekl:
RelieF Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
n',
Closed TigE`tt �
Op�nc� at
Opined at
vsid
�', :.
Tilt ,_
RP- , -1 _ (vsid
Leaked o
� .� psid
vsid
Leaked �
Did noc Opm o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opmcd at
Opined at
vsid
Repair
Tight o
vsid
vsid
RP std
The above is certified to be true. �/ea
Firm Name ��, 5�i2�fr•••+ -rd1 �,. Certified Tester �. L" „� � _ .. '”
-t•
�' s , ,. ,.
Firm Address �DaZ �a✓l /�• 1 -lC�[- � - Cctt Tester No(,'�"t?f�c� � % �� Date �' / ! .> %%
gauge # <� (� L/ L/
Date last accuracy tested f <'� r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy