2012_0420 (10)CHECK ONE_
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST' AND MAINTENANCE REPORT
NAME OFPWS: �-�7�, G'F- lc-n�� -�/
PWS I.D_ � � �s 1(-r-
LOCATION OF SERVICE: �� dy �J t ✓ i � e� d
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
rc��ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle C Pressure Va�-uL**n Breaker
�57� D/oulble Chock Valve o Atmosphere Vacuum Breaker
Manufacturer [.lJ � T T 5 Size �/„�
Model Number ^UO� W► ? Located AL yt/� e 7 a� [CZ S ��c �' s- tc% C c� /.•/ p
Serial Number /`) �GGo � r!i y � /�= (•'`f �' 1ro� t T
The about is certified Lo be trot. y -P S
Firm Name �� T °"y-✓ f � � � � Certified Tester �-- �I�G -1 ke- lilJ � �. �t ✓
Firm Address *-'�% �°%'` �%% CerL Testa No. �PPp�'�i`�,�Date t���li a-
{�GyO� VtcEln --G
Gauge # 3 � �C[ �
Date Iast accuracy tested '��� (/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRRa.7.'FR
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
It:itial Test
DC- Closed
Ti�it �_ '- i �
Closed Tight QY
Lcakcd (_ G/ O
Opened at
nsid
Opened at
nsid
nsid
RP- nsid
Leaked o
Did not Opea o
Leaked o
Reaairs
and
Materials
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tighi o
nsid
nsid
RP sid
The about is certified Lo be trot. y -P S
Firm Name �� T °"y-✓ f � � � � Certified Tester �-- �I�G -1 ke- lilJ � �. �t ✓
Firm Address *-'�% �°%'` �%% CerL Testa No. �PPp�'�i`�,�Date t���li a-
{�GyO� VtcEln --G
Gauge # 3 � �C[ �
Date Iast accuracy tested '��� (/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy