2011_0405CIIECi� ONE.
IRRIGATION DOMESTIC V'` FIRELINE
BACI{I'ZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: G � �" _X, v* � E-.G i}e c 1-d- --
PWS I.D. # �
LOCATION OF SERVICE: I I I I FR E� F�c'!' � P K W Y
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle D Pressure Vacuum Breaker
Double Check Valve � Atmosphere Vacuum Breaker
ag
Manufacturer u.> i j i< I N S Size
Model Number qSa Located At � i SEi2 %i��/�Yh
Serial Number � Q ♦1 g 3
The above is certified to be true. �/�'.5 , �f'
Firm Name i� 1 2r= fa✓Arc� ..tiJG Certified TesterQ��� -���- �� , ��F��
Firm Address 10.T 6 $ �V1 i � t � Rd • f d -x Cent_ Tester No�L� � �� Date � �-� `'
Gauge # c7+. � 9 '-/ �•1 �!
llate last accuracy tested f ^3 �''j
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT."F'R
Double Check Valve Assembly
1st Chec3:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed � • �
Closed Tim "t '@f
Opened at
Opened at
vsid
Tilt �
Leaked o
psid
vsid
�`'' � �"
RP- vsid
Leaked �
Did not Open o
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opeucd at
osid
Repair
Tight �
vsid
osid
RP std
The above is certified to be true. �/�'.5 , �f'
Firm Name i� 1 2r= fa✓Arc� ..tiJG Certified TesterQ��� -���- �� , ��F��
Firm Address 10.T 6 $ �V1 i � t � Rd • f d -x Cent_ Tester No�L� � �� Date � �-� `'
Gauge # c7+. � 9 '-/ �•1 �!
llate last accuracy tested f ^3 �''j
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy