2011_0401 (2)CHECK ONE. '
IRRIGATION DOMESTIC FIRELINE t'
BACKF'I.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �...: �t�`� �,_:, � -.�,,�
PWS I.D. # �/ � i� 4
LOCATION OF SERVICE: / � � .S FR c �' �2 �- P �''" Y
The backllow 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 ` Reduced Pressure Principle � Pressure VacuL�**? Breaker _
Double Check Valve o Atmosphere Vacuum Breaker
` - � �/
Manufacturer 1/V.flr-� _f . 3 Size
Model N�ber '7 '% J Located At �%/; U�- f / IJ Grf-I.fS
Serial Number / � � �D 8 — C� .3 O 7
The above is certified to be true.
Firm Name Y � -�..> Certified Testa !�f/- ���= .��i°.�ch`'%
Firm Address s- � - - _ - Cert. Testa N�'�� Date �/ f/
Gauge #
Date Iast accuracy tested r"� .:✓ ;� "' /,
White — Customer's Copy Yellow —City Copy PinK — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight � e`�
Opened at
Opened at
vsid
_
Ti°hL � -" _ ��
Leaked o
psid
vsid
RP- DSld
Leaked [7
Did noc Open o
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at
Opened at
vsid
Repair
Tight o
psid
vsid
RP std
The above is certified to be true.
Firm Name Y � -�..> Certified Testa !�f/- ���= .��i°.�ch`'%
Firm Address s- � - - _ - Cert. Testa N�'�� Date �/ f/
Gauge #
Date Iast accuracy tested r"� .:✓ ;� "' /,
White — Customer's Copy Yellow —City Copy PinK — Tester's Copy