2012_0312 (4)CIIECii ONE::
IRRIGATION DOMIS'TIC_ O FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � /'7 `� L'� F' lc-- (�Pr //
PWS I.D. #
LOCATION OF SERVICE: _�d� A t./L/ -✓C � r-
The backilow prevention assembly detailed betow has been tasted and maintained as required by TCEQ
regulations and is certified to he operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressm•e Principle a Pressure Vacsntm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer F.tJ4 7T S S i �P a � �
Model Number � 0 �% wt t Located At yH � d � 1 <
f -/!o yc Z./ - -./ � C U �
Serial Number � c� �•i 6 0� � �t%S � s� � � � � � v �� � •�v 5
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PR.IPICTPLE ASSEMBLY
PRESSURE VACU'LTM BRF_AitF'R
Double Check Valve Assembly
1st Cheri: 2nd Cheri: Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed Closed Tight Agtj Opened at
Opened at nsid
Tight p-!- ` � Rp Leakexl � e-I a nsid
nsid
RP- nsid
��� C'
Did aoc Open o Leaked o
Repairs
and
Mat:crials
Used
Test .After
DC- Closed Closed Tight o Opened at
Opea� at nsid
Rapair
Tight Q nsid
nsid
RP rid
The above is
crstifie� to be true.
Firm Name A�
� '�' "} �� �- Certified Teste
- °2
Firm Address
�1
Pct �a� -% �% 7 Celt. Tester No. i
� � Date 31�r�� / oZ
C >>GC ►^ Q C• N �c
Gauge �
3 y a s/ E3
Date last accuracy tested � � //
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy