2011_0531 (3)CiIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKF'I.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
o Reduced Pressure Principle � Pressure Vacu�nn Breaker
�'II, Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer S"
Model Number
Serial NLmmber
ize
Located At
The above is certified to be true.
Firm Name • �J� T ` .� �A� 1C�L -OV�.�
Firm Address -S��OB � VPo �T� ��"
Gauge # ? �z T�
Date last accuracy tested
Certified Tester
CaL Testa No. Date _ ' �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLTiJM BR��F'R
Double Check Valve Assembly
1st ChecS:
2nd Check
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Closed Tight Q
Opined at
Opined at
vsid
Ti°bt %L7,
Leaked o
psid
vsid
RP- � vsid
.
Leaked o
Did not Opm o
Leaked 0
Repaits
and
Materials
used
Test Afies
DC- Closed
Closed Tight o
Opmcd at
Opined at
vsid
Repair
Tighi o
vsid
vsid
RP sid
The above is certified to be true.
Firm Name • �J� T ` .� �A� 1C�L -OV�.�
Firm Address -S��OB � VPo �T� ��"
Gauge # ? �z T�
Date last accuracy tested
Certified Tester
CaL Testa No. Date _ ' �
White — Customer's Copy Yellow —City Copy Pink — Tester's Copy