2011_0531 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE '``�
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAIi�TI'ENANCB 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 o Pressure Vacutmm Breaker
�7. -, Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At ���J`f � �!XJ/�'t ��'�
Serial Number
The above is certified to be true.
Firm Namc _- = �_- t o ".
Firm Address SO :� S/ r 1 vN �-� f , i C
Gauge # 3�Z � Go
Date last accuracy tested
Certified Tester
CerL Tester No.
- Date r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACLJLTM B�F'�TrFR
Double Check Valve Assembly
1st Chekl:
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight �3�
Opined at
Opined at
nsid
Ti°hL ,¢.,
Leaked o
psid
nsid
RP- :. .. nsid
Leaked 0
Did not Opm o
Leaked o
�Paz�
and
Materials
Used
Test ARcr
DC- Closed
Closed Tight t7
Opm«i at
Opined at
nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Namc _- = �_- t o ".
Firm Address SO :� S/ r 1 vN �-� f , i C
Gauge # 3�Z � Go
Date last accuracy tested
Certified Tester
CerL Tester No.
- Date r
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy