2012_0111 (2)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE ✓
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �r�, Gp �"22e
PWS I.D. #
LOCATION OF SERVICE: 651 N MccGArAur- - Bon L GP Taco
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
,' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer men Size ny q
Model Number )0oo 3,� Located At S- Poo,
Serial Number ``7 72117
The above is certified to be true.
Firm Name 1411 -2�51
Firm Address /�iClr n Vt
Gauge # CJ(o 11 CEO (D cj
Date last accuracy tested 8- e- /(
Certified Tester /of- kn o Q
01 V
Cert. Testa No. Bffjc)/37ql Date 1-11-12-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,Z
Opened at
Opened at
psid
Tight
Leaked ❑
Leaked ❑
2.2
psid
psid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
r)sid
Repair
Tight ❑
psid
pSid
RP sid
The above is certified to be true.
Firm Name 1411 -2�51
Firm Address /�iClr n Vt
Gauge # CJ(o 11 CEO (D cj
Date last accuracy tested 8- e- /(
Certified Tester /of- kn o Q
01 V
Cert. Testa No. Bffjc)/37ql Date 1-11-12-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy