2011_0401 (2)CHECK ONE_
IRRIGATION
DOMESTIC
FIRELINE
BACKF'I..OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D- #
LOCATION OF SERVICE: % � 7.S /` i -C t- >P!?r -,� `�!� - -�- � f -
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 a Pressure Vacuum Breaker
Double Check Valve '* e Atmosphere Vacuum Breaker
Manufacttrrer - -'i✓� ° .f � ': Size .j�`r
Model Number �J O � � � Located At L'l ' `'��
Serial Number / � d '�
The about is certified to be true. -y � S .
Firm Name %��.� Fi /1 �P Gi v� � � n Certified Tester /mot/- lX��'�f�� t'` ^ -
Firm Addrrss i D a. % $ M � �--� PsL QcQ �1 � 7 Cent Testa No. ? =� ®OD.�i % c� � Date
Gauge # J � � �/ � j �i
Date last accuracy tested %_3 �— f f
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
4
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY'
I PRESSURE VACUUM BR��IL'F_R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
osid
�f1S5r�:'
Tight ` `'Y O
RP- osid
Leaked o
psid
osid
Leaked o
Did not Open o
Leaked a
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight �
Opened at
Opined at
osid
Repair
Tight 0
osid
osid
RP sid
The about is certified to be true. -y � S .
Firm Name %��.� Fi /1 �P Gi v� � � n Certified Tester /mot/- lX��'�f�� t'` ^ -
Firm Addrrss i D a. % $ M � �--� PsL QcQ �1 � 7 Cent Testa No. ? =� ®OD.�i % c� � Date
Gauge # J � � �/ � j �i
Date last accuracy tested %_3 �— f f
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
4