2012_0312CiIi:CK ONEc
IRKIGATION
DOISd1 =STIC
FIKELINE
BACI�I�OW PREVENTION ASSF.NII3LY TEST AND MAIN'T'ENANCE REPORT
NAME OF PVS7S: � i .7 �,� C°' (' l c-- !_� � �- � r
PWS I.D. #
LOCATION OF SERVICE: �C� /4 �✓L �.�r %�,�
The bsackflow prevention assembly detailed below' has been tested and maintained as required by TCEQ
reeulations and is c:ertihccl to be operating within acceptable parameters.
TYPE OF ASSEMBLY
n Rctluc� Pressures Principle Q Pressure Vain•+*+ Breaker
Double Chxk Valve D Atmosphere Vacuum Breaker
Manufacturer Vt./�.77 5 Size 3l�/
Model Number dy7 N�1 a Located At S' �% �%x-' U L �i
serial Number O � �/ 3 �'
White - Customer's Copy Yellow -City Copy Pink - TesteCs Copy
REDTJCED PRESSURE PRI?�ICIPLE ASSEMBLY
PRESSURE VACL'LTM BRFatr�R
Double Check Valve Assembly
1st Cheri:
and Cheri: Re3ief Valve
Air Inlet
Cheek Valve
Initial Tai
DC- Closed
Closed Tislzt � Opened at
Opened at
osid
Ti>�t /• �j S$1
Leaked / -Q D osid
osid
RP- nsid
I.eai:ed �
Did nor Opm
Q Leaked �
�P ��
and
Materials
used
Test Aiirs
DC- Closed
Closed Tight o Opmcd at
Opined at
osid
Repair
Tight o
osid
osid
RP sid
The about is certified to be true.
Firm Name JQLTIu.�I
�� �-
Certified Tesler
���-
Firm Address
QO � G� iC 7 9 7
Ces't_ Tester No.
� G 7 Date
3 / �� / a
/,Uc � a to G N � c
Gauge #
3� �/ �* � °�
Date last accuracy tested �
/ /�
White - Customer's Copy Yellow -City Copy Pink - TesteCs Copy