2012_0718CIIECK ONE:
IRRIGATION_��
DOMESTIC
FIRELINE
BACKFLO /W�PRlEVENTIO%N�ASSEI��LiY TESTf' AND n CE REi'ORT
NAME OF PWS. l._ i� 1 �/ �i � l_[�I, �' 1 � l iP S. (�� P �I � � �� � � ,T -�
PWS I_D_ # / _ '� S � % %
LOCATION OF SERVICE: �x,Iz �' Cl ma)-c t P a �� %J • �XZ-�Ai'1 e� �l 7�i0 / �/
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 Reduccdi Pressure Principle o Pressure Va�mm Breaks
�1 Double Check Valve O Atmosphac Vacuum Breaker
Manufacturer �P {� G D Size � '
Model Number _ .'�� a X �. % Located At '�%�) . �����. -: � LL�2.fi4Q -f�IPn �/- I,t- ,dVYl�ttyi
Serial Number � r J — - '� � � � 3
The above is certified to be true_
Wtigtu Blow 8 PLBCi
Firm Name Certified Tester � o� n e v � it r . � �f
Fir_ m Address '��� Cert Tester No��0�7S�D� - �'v
-7 -ice -�z
Gauge # I 3 'g_ Q, z 3 \mil ct � �s T K - 9 cj L�
Date last accuracy tested j'_ 5
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACi.7fJM BRFSKFR
Double Check Valve Assembly
1st Check
tad Check
Rni:ef Valve
Air Inlet
Check Valve
Initial Tess
DC- Cioscd
Closed Tight o
Opened at
Opeaod at
nsid
�i ��
Ti�tt o
RP- t�- J psid
Lcalcd �
Leaked o
_
Z` Z
nsid
nsid
Did sot Open o
Leaked o
Repairs
sad
Materials
Used
Test ARrr
DC- Closed
Closed Tight O
Opened at
Opened ai
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certified to be true_
Wtigtu Blow 8 PLBCi
Firm Name Certified Tester � o� n e v � it r . � �f
Fir_ m Address '��� Cert Tester No��0�7S�D� - �'v
-7 -ice -�z
Gauge # I 3 'g_ Q, z 3 \mil ct � �s T K - 9 cj L�
Date last accuracy tested j'_ 5
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy