2011_0308 (3)CHECK ONE.
IRRIGATION DOMESTIC FIR ELIN E
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERVICE: `"
The backflow prevention assc;mbly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
'>xi Reduced Pressure Principle D Pressure Vacuimm Breaker
o Double Check Valve � Atmosphere Vacuum Breaker
ii
Manufacturer Size `% '
Modei Number - - Located At _`� ,` t : , � .
Serial Number
The above is certified to be true.
Firm Name I � Y� i � rLl m�� i = ; Certified Tester _ ;'t ,
Firm Address � «�t � � lU/1 LV _ is'l� CerL Testa No � _t' . , �t i 1 +'_ Date � �
TJ� a � , `T7c -713
Gauge # ���7 � ��
Date Iast accuracy tested � �o� � ,
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAi.'F'R
Double Check Valve Assembly
1st Chec3:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed f
Tight >ti
Closed Ti�h[ ®�
Leaked o
Op at
psid
Opined at
osid
osid
RP- osd
Leaked o
-
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test Afars
DC- Closed
Closed Tight o
Opined aL
Opined at
osid
Repair
Tight �
nsid
osid
RP sad
The above is certified to be true.
Firm Name I � Y� i � rLl m�� i = ; Certified Tester _ ;'t ,
Firm Address � «�t � � lU/1 LV _ is'l� CerL Testa No � _t' . , �t i 1 +'_ Date � �
TJ� a � , `T7c -713
Gauge # ���7 � ��
Date Iast accuracy tested � �o� � ,
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy