2011_0308 (4)CIIECK ONE.
IRIZ.IGATION llOMESTIC . -' FII2ELINE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: x _
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
d Reduced Pressure Principle o Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer � ; °`� ` � Size
Modei hiumber Located At � ' �` '.,; ? ` ,'
Serial Number '
'
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�'R
Double Check Valve Assembly
1st Checl:
2nd Chek:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�h[
Opened at
Opened at
nsid
Tight ,. _.
Leaked �
nsid
nsid
RP- nsid
Leaked �
Did not Open �
Leaked o
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
�yp �p r
Firm Name E'S t � E_U f V l'Q �Zi 11 1 CZ(�:. -. Crrrifie� T�ettr _ s r i ,
Firm Address � � � o t''' G�,Y�I� �� . Cert. Tester No. ' =; t '. : ' Date i F
Da 11z� , -i�X `7 ��43
Gauge # ��j[� -%� (��cj ��yy
Date last accuracy tested �-ec �- +�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy