2012_0316 (3)CIIL•:CK ONE:
IRRYGATION DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: �-i7`l L''F !c�(- ��r-ti
PWS I_D. #
LOCATION OF SERVICE: � �% � � � ✓ 1 ci �.� d
The backtlow 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
� Reduced Pressure Principle D Pressure Vacutna Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacziser W � �� � `] Size �-�
Model Number C�c� -7 WI l Located At �YL'1 e Tc.� Q ..� � "mil r
Serial Number /� � 6C? C1 a
__ - --
REDUCED PRESSURE PRI?YCIPLE ASSEMBLY PRESSURE VAC'LTTJM BRF'a7rF-R
Double Check Valve Assembly
1st Chec3: tad Checl:
Relief Valve Air Inlet Check Valve
/
Initial Tcst DC- Closed /� �
Closed Ti�hL �F]
Opmed at Opened at nsid
Tight td
Leaked �_ G o
nsid nsid
RP- nsid
Lcai:ed C
Did noc Opea Q Leaked O
Repairs
and
Materials
Used
Test AR.er DC- Closed
Closed Tight o
Opened at Opened at � sid
Repair Tight t�
nsid nsid
RP sid
The above is cerri£ed to be true. �P 5
Firm Name �CnT <<+�.% �� �e Certified Tester � ®taJr�u.v�- W -e.nv� ¢/
Firm Address Yo � ew 7 i % Ctrt. Tester No. �f Do6'fi ° /�� Date 3��G��'�
k��c�c h c c k• z
gauge # 3 � �/ 4 /�
Date last accuracy tested ,5 �//
White - Customer's Copy Yellow -City Copy Pink - Te_ster's Copy