2011_0531 (7)CIIEC,K ONE.
IRRIGATION DOMESTIC FIRELINE
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: `-
PWS I.D. #
LOCATION OF SERVICE:
The backtlow 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 Reduc�i Pressure Principle o Pressure Vacuimm Breaker
'O . Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size ,�'`'
Model Number � Located At K7/ >>f
Serial Number
The above is certified to be true.
Firm Namc . �= t � (� - l:J,�iC 1c 1= �..0 YJ
Fins Address sL%s � Vl°YL1 -�� 7��
Gauge # 3 7 Z ��
Date Iast accuracy tested 2 - �- � F
Certified Tester
Cezt. Tester No. - Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEl�LBLY
PRESSURE VACUUM BR��R
Double Cheek Valve Assembly
1st Checl+
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,�1
�
Opined at
Opined at
Dsid
Tight 4
Leaked o
psid
osid
RP- `- nsid
Lcai:ed a
Did not Opm o
Leaked o
Repairs
and
Materials
Used
Test Ages
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Namc . �= t � (� - l:J,�iC 1c 1= �..0 YJ
Fins Address sL%s � Vl°YL1 -�� 7��
Gauge # 3 7 Z ��
Date Iast accuracy tested 2 - �- � F
Certified Tester
Cezt. Tester No. - Date
White - Customer's Copy YeIIow -City Copy Pink - Tester's Copy