2011_0531 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELYNE
BACKFT,OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: -
PWS I_D- #
LOCATION OF SERVICE: �:_ � _
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certited to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduc.�d Pressure Principle D Pressure Vaculmz Breaker
O, Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer ,.- lt" d `=- 'y' Size
Model Nlltclber T-�,G/ Located At ±" � � -%
serial Number S /y .�l' a7 �q � � e�
The above is certified to be true.
Firm Name - � T � �> �- %�,= �- -���"�
Firm Address _S o l08 //�// v� ry 1 G i 7So 5 u
Gauge # �%� `7-Cp
Date last accuracy tested
Certified Tester 5��--T /"i /RSDOT/
Cert. Tester No. Z SZ � Date g - 3 / -
White - Customers Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFas.�R
Double Check Valve Assembly
1st Checl:
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closcd
Closed Tight .Ps�
Opened at
Opened at
DSld
Ti°}1L �F E�
RP- nsld
Leaked o
nsid
nsid
Leaked o
Did not Open o
Leaked �
Rcpaus
and
Materials
Used
Test AR.er
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight C7
nsid
nsid
RP sid
The above is certified to be true.
Firm Name - � T � �> �- %�,= �- -���"�
Firm Address _S o l08 //�// v� ry 1 G i 7So 5 u
Gauge # �%� `7-Cp
Date last accuracy tested
Certified Tester 5��--T /"i /RSDOT/
Cert. Tester No. Z SZ � Date g - 3 / -
White - Customers Copy Yellow -City Copy Pink - Tester's Copy