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2011_0422 (15)
CIIECIi ONE: IRRIGATION DOMESTIC FIRELINE BACKFI.OW 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 � Reduced Pressure Principle O Pressure Vag-+•+***+ Breaker o Double Check Valve � Attnospherc Vacuum Breaker Manufacturer Sue Model Number Serial Number Located At - REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACL7UM BRF'aI�' -F'R Double Check Valve Assembly 1st Checl: 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Tight ©-. Opened at Opened at osid Tight o _Closed Leaked � psid osid RP- osid Leaked o Did not Open o Leaked � Repairs and Materials Used Test After DC- Closed Closed Tight O Opened at Opened at osid Repair Tight 0 osid osid RP sid The above is certified to be true. Firm Namc Firm Address Gauge # Date last accuracy tested Certified Tester - -- Ccrt. Tester No. � Date `f White — Customer's Copy Yellow —City Copy Pink — Tester's Copy