2011_0308 (2)CIIECK ONE:
IRRIGATION y � DOMESTIC
FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: _ 1 ,_ : '• r. -" i s ;
PWS I.D. #
LOCATION OF SERVICE: i : " _ • ; %`
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is cerCifiied to be operating within acceptable parameters_
TYPE OF ASSEMBLY
O Reduced Pressure Principle � Pressure Vactnmi Breaker
�' Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer ` ,a '�� ' Size ' � i!
Model Number ' :; i � � Located At � �.%iY � y„�^1 PK i I y F.� U?PiY ��%1 �li�'�
Serial Ntmmber �i t � - � VV'P�
The above is certified to be true.
Firm Name Vl �� � � �" CE �'e �2U'l l
Firm Address ! ! �_, g o �dno i2Lr
n Ju l t�s, TX `143
Gauge # [ /5���5
Date Iast accuracy tested g-- a!- ((7
Certified Tester
�.:
Cert. Tester No ' � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'�'R
Double Check Valve Assembly
1st Cheese
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed /
Closed Tight IS`
Opined at
Opined at
osid
Tight ,�:.`� d
Leaked �
psid
osid
RP- osid
Leaked �
�
Did not Opm o
Leaked �
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opmcd at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name Vl �� � � �" CE �'e �2U'l l
Firm Address ! ! �_, g o �dno i2Lr
n Ju l t�s, TX `143
Gauge # [ /5���5
Date Iast accuracy tested g-- a!- ((7
Certified Tester
�.:
Cert. Tester No ' � Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy