2012_0312 (6)cIII:cI; oNE:
IRRYGATION
D C3 M ESTIC
FIREZ.INE
BACKFLOW PREVENTION ASSENII3LY TEST AND MAINTENANCE REPORT
NAME OF PWS: � � ? `� L'y (-' !c, n fJ, --!!
PWS I.D. #
LOCATION OF SERVICE:. �O � � t � L � .•-%e (-� �/'
The backflow 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
n Reduced Pressure Principle O pressure Va.- *n.+�+ Breaktr
Double Chccl: Valve O Atmosphere Vacuum Brcaler
I�Sanufacturer F.tJG Tpi S Size � t•
Model Zvumber � �
Serial Ntanber % % 7 �%� O
Located At �- � i% ¢ v L �
The above is cerrit:'ted io be ttue-
Film Name � Gn � ��n/ �� .e
Firm Address Pd � o x -7 �% �
gauge # 307 t/ � / B
Date Iast accuracy tested .'> l!/
Certified Tester p "�-
CerL Tester No. F �d °��o� S Date 3 l.� /� a
White - Customers Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEi►�LBLY
PRESSURE VACU'CTM BRFarr�R
Daubie Check Valve Assembly
1st Check
tad ChecI:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
TiQhL �.� �
Closed Ti�hL �7
Leaked � 8 O
Opened at
nsid
Opmed at
nsid
nsid
RP- nsid
Lcai:ed O
Did not Open O
Leaked O
Repairs
anal
Materials
urea
Test ARer
DC- Closed
Closed Tight O
Opaaed at
Ogmed at
nsid
Repair
Tight O
nsid
nsid
RP sid
The above is cerrit:'ted io be ttue-
Film Name � Gn � ��n/ �� .e
Firm Address Pd � o x -7 �% �
gauge # 307 t/ � / B
Date Iast accuracy tested .'> l!/
Certified Tester p "�-
CerL Tester No. F �d °��o� S Date 3 l.� /� a
White - Customers Copy Yellow -City Copy Pink - Tester's Copy