2011_0531 (9)CiIECI� ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIl�iTENANCE 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 a Pressure Vacuum Breaker
� Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer Size 3J <} JJ
Modei Number Located At V � F
Serial Number ._ _ __
The above is cctti£ed to be true.
Firm Name . yU f i .ry �/i c '� � LO t .,
Firm Address SD%8 f�Vc 12 ��. '�C , ! S::i� �.
� —��-
Gauge # 3 %z �� ,�
Date last accuracy tested ,
Certified Tester '
Cert. Tester No. _- _ _ -
Dau �- � '
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight [�.
Opened at
Opened at
nsid
Tight_,, �,
Rp_ _rte nsid
Leaked � �
psid
nsid
Leaked D
Did nor Open D
Leaked D
�Pa�
and
Materials
Used
Test AfTrs
DC- Closed
Closed Ti�Qht o
Opened at
Opened at
nsid
Rtpair
Tight D
nsid
nsid
RP sid
The above is cctti£ed to be true.
Firm Name . yU f i .ry �/i c '� � LO t .,
Firm Address SD%8 f�Vc 12 ��. '�C , ! S::i� �.
� —��-
Gauge # 3 %z �� ,�
Date last accuracy tested ,
Certified Tester '
Cert. Tester No. _- _ _ -
Dau �- � '
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy