2011_0401 (3)CIIECIi ONE.
IRRIGATION
r.
DOMESTIC i•`
FIR E LIN E
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �- t _�:. _ �_ "_�!.%t' r`_ C
PWS I_D. # ���
LOCATION OF SERVICE: 1 � r %_�i .�' /� C l' '�eiC%/� f Pll +..�'
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 n Pressttrc Vacuum Breaker
� D,,o--u}ble Check Valve '2 o Atmosphere Vacuum Breaker
Manufacturer W.'� ,r � --5 Size _QL
Model Number C: O�(m a Located At K i _SC2 �Oy�
serial Number �} � i yob
The above is certified to be true_ -.
Firm Name � -F = =' ,' ,
Firm Address ?�� �' `; , .
Gauge # .� � q ti'-/ �
Date Iast accuracy tested � -3 � ` ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
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REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Cbecl:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
e
1""� �
DC- Closed __
Tilt <.'�� -`-'
RP- nsid
Closed Tigh�' -�f
Leaked o
Opened at
�>.`-;� psid
Opened at
nsid
nsid
Leaked o
Did not Open D
Leaked D
Repairs
and
Matczials
Used
Test ARer
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 � -F = =' ,' ,
Firm Address ?�� �' `; , .
Gauge # .� � q ti'-/ �
Date Iast accuracy tested � -3 � ` ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
�,