2012_0420 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: (��- / ? `� C� F- l c- (� � r ! /
PWS I.D. � > t �>c.J ��-C-
LOCATION OF SERVICE: L[ DO �s �J 4 cl e r�
The backflow prevention assembly detailed belo�� has been tested and maintained as required by TCEQ
rceulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o Reduced Pressuia Principle C Pressure Vag-+*+•+*+ Breaker
� Dou-blle Check Valve � Atmosphere Vacuum Breaker
Manufacturer Wei = % ^^5 /� Size C
Model lvimmber % 7L� �7 � AA' Located At J - �i (�L' �i [_.
Serial Ntmmber � � D � !�! ��
The above is cer-tificd to be true. �/r �j
Firm Name �C's i� ..1 �'. l e Certified Testa �---� We -s v. � (,el+t� v. ,�t P i
Firm Address I �-' �b�' � S 7 Cent_ Tester No. 1Di 8 Cc� ci �.� S Date � 1 /� �� a
4.� c y� 4' c, h �c
Gauge # 3 � L% �
Date Iast accuracy tested � �/1
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Chec4:
2nd Checl:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC -Cl ed
Tit � CU j�
Closed Tight �
Leaked 3 � D
Opened at
osid
Opined at
� sid
osid
RP- osid
Leaked D
Did not Opm o
Leaked �
RcPai�-e
and
Materials
Used
Test Afier
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Repair
Tight �
osid
osid
RP sid
The above is cer-tificd to be true. �/r �j
Firm Name �C's i� ..1 �'. l e Certified Testa �---� We -s v. � (,el+t� v. ,�t P i
Firm Address I �-' �b�' � S 7 Cent_ Tester No. 1Di 8 Cc� ci �.� S Date � 1 /� �� a
4.� c y� 4' c, h �c
Gauge # 3 � L% �
Date Iast accuracy tested � �/1
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy