2012_0420 (2)CIIECI{ ONE.
IRRIGATION DOMESTIC FIRELINE /v
BACKFLOW PREVENTION ASSEMBLY TEST' AND MA.IIV'I'ENANCE REPORT
NAME OF PWS: (�L- � .T `� L� F- L c'� �- � /
PWS I -D. # l (lC��, l��
LOCATION OF SERVICE: L10� iJt a/ t d �°v, c�
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 Vag^ ^^+�+ Breaker
.� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �l.% T T J� Size 1
Model Number � % �� �e p� Located At �b R'r� tJCc� L
Serial Number l o o a l 3[� � `�
The above is A^cetified to be true. �/ t�5
Firm Name /J G T ipy-✓ �7 ✓e Certified Tester pp� lt� -+ ✓t G %l1 C v� ✓f P�
Firm Address � � �>< % � �% Cent Tester No. C��C�cc)�/eJa � Date ��I� -� /a-
G-+CQ 1nr Gh �c
Gauge # �� c� Cj f c5
Date Iast accuracy tested j � ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACL1iJM BRE_A��'R
Double Check Valve Assembly
1st Check
2nd Checi:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC -Clo ed
Closed Tight th0
Opened at
Opened at
nsid
Tilt ��,® Ik9
Leaked ?j,� �
psid
nsid
RP- nsid
Leaked �
Did not Opea �
Leaked �
Repaus
and
MatcriaLs
Used
Test After
DC- Closed
Closed Tight o
Opened aL
Opmed at
nsid
Repair
Tight t7
nsid
nsid
RP sid
The above is A^cetified to be true. �/ t�5
Firm Name /J G T ipy-✓ �7 ✓e Certified Tester pp� lt� -+ ✓t G %l1 C v� ✓f P�
Firm Address � � �>< % � �% Cent Tester No. C��C�cc)�/eJa � Date ��I� -� /a-
G-+CQ 1nr Gh �c
Gauge # �� c� Cj f c5
Date Iast accuracy tested j � ��
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy