2011_0427 (3)CIIECI� ONE:
IRRIGATION
llOMESTIC
FIR ELIN E
BACTUFFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
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
Q Reduced Pressure Principle � Pressure Vacutmm Breaker
o. Double Chec.�: Valve � Atmosphere Vacuum Breaker
Manufacturer Size
Modei Number Located At
Serial Nimmber
The above is certified to be true.
Firm Name ,���� � Jc. i7 �.4 e
Firm Address �Q- �x ��.� �� k "-
Gauge # � / /'Qd
Date last accuracy tested - 1 f - / :�
Catified Testa ��.'�`. %,`; <_�,. , ;
Cert. Testa No. Dace
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFaI.'FR
Double Check Valve Assembly
1st Chec3:
2nd Checi:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tight �
Leaked o
psid
nsid
RP- nsid
Lcaked �
-
� � '�
Did not Open o
Leaked a
�P��
and
Materials
Used
Test ARa
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight Q
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ,���� � Jc. i7 �.4 e
Firm Address �Q- �x ��.� �� k "-
Gauge # � / /'Qd
Date last accuracy tested - 1 f - / :�
Catified Testa ��.'�`. %,`; <_�,. , ;
Cert. Testa No. Dace
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy