2011_0401 (3)CIIECK ONE.
IRRIGATION
DOMESTIC
FIRELIN
BACKFZ.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: €.__ : -1 � �..,. t=-�� ��,�`" !__ �-
PWS I_D. # � fO�
1:^ 7 L�
LOCATION OF SERVICE: �' � -i < °' � =' ✓~ -�� ��'� f '`� "�'i
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 Reduc. -d Pressure Principle o Pressure Vac -+n�rn Breaker
t�`� Double Check Valve - D Atmosphere Vacuum Breaker
Manufacturer ?�..1 Size '' �`'' '
Model Number Located At �,•!. # - ' >; - ` '
Serial Number
The above is certified to be true_ ,
Firm Name �
Firm Address -
Gauge # � � , , r
Date Iast accuracy tested / - ._
��'
Certified Testa L��� -Y-��
� f
Cent Tester No.xl�OO� 37 �''.� Date �'�/ '' .jl i
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACiJI.7M
BRFAT`�R
Double Check Valve Assembly
1st Checl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed,_,
Closed Tigfit "^GY
Opened at
Opened at
vsid
p,45SGGQ
Ti�tt + -' -� ®`
RP- vsid
Leaked o
psid
osid
Leaked D
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test AR.er
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Rrpair
Tight o
vsid
vsid
RP sid
The above is certified to be true_ ,
Firm Name �
Firm Address -
Gauge # � � , , r
Date Iast accuracy tested / - ._
��'
Certified Testa L��� -Y-��
� f
Cent Tester No.xl�OO� 37 �''.� Date �'�/ '' .jl i
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy