2012_0420 (5)CHECK ONE.
IRRIGATION V / DOMESTIC
FIRELINE
BACTiFLOW PREVENTION ASSEIV�LY TEST AND MA.I2�TI'ENANCE REPORT
NAME OF PWS: �. � �� ` L` F-
PWS LD. # C� K(-�e
LOCATION OF SERVICE: t(Ot� `� t � t � zi(.° d
The backtlow prevention assembly detailed bclo4v has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Rcduc�i Pressure Principle C Pressure Va�-ttL*+*+ Breaker
'Qj Double Check Valve � Atmosphere Vacuum Breaker
.,
Manufacturer �/lJc � 1 S Size r�
Model2NUmber /) Cio`i IM ( Located At �' f/yleTrs �,J S��t T
Serial Number /'7 � � G 3
The above is certified to be true- y/�5
Fitm Name t4C TC��I �-' • /e Certified Tester �/_� n� f�:� -� v�C- L� P do 'Nl P/
Firm Addtrss 1' � NCB 7C � i �% Cert- Teste No- L`�f �<'�oC7��3 Date `���'�I�
gauge # 3 � c/�=j /�y
Date Iast accuracy tested � % //
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY" PRESSURE VACUUM BRE_A�'F'R
Double Check Valve Assembly
1st Cherlc
tad Cheri:
Relief Valve Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tit �_ �, Q2>f
RP- psid
Closed Tight to
Leaked � y �
Opined at Opined at
psid psid
psid
Leaked �
Did not Opm O
Leaked D
Repaus
and
Matciais
Used
Test Auer
DC- Closed
Closed Tight D
Opined at Opined at
psid
Repair
Tight o
psid psid
RP sid
The above is certified to be true- y/�5
Fitm Name t4C TC��I �-' • /e Certified Tester �/_� n� f�:� -� v�C- L� P do 'Nl P/
Firm Addtrss 1' � NCB 7C � i �% Cert- Teste No- L`�f �<'�oC7��3 Date `���'�I�
gauge # 3 � c/�=j /�y
Date Iast accuracy tested � % //
White - Customer's Copy Yellow -City Copy Pink - Testers Copy