2012_0111 (3)CHECK ONE:
IRRIGATION DOMESTIC ;� FIRELINE
BA=OW PRjEVEN 1ON ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CI l" OF 21
PWS I.D. #
LOCATION OF SERVICE: 80"1 Al MQcA Lr 0yd — & i GT
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.
❑ Reduced Pressure Principle
43-1 Double Check Valve
Manufacturer \Ak /J,5
Model Number Oo7,412
Serial Number ! 02n %
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size l/.21
Located At m d eT
The above is certified to be true.
Firm Name 411 -7
Firm Address -rSY$ AA-,) V'e(,.,
Gauge # 0(Q j j00(e j
Date last accuracy tested e- 0- / 1
Certified Tester )Oe kn Gn
Cert. Testa No. Ai0135yl Date
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
Tight W
RP- L�,psid
Leaked ❑
Closed Tight Ar
Leaked ❑
Opened at
psid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight O
Opened at
osid
Opened at
nsid
psid
RP sid
The above is certified to be true.
Firm Name 411 -7
Firm Address -rSY$ AA-,) V'e(,.,
Gauge # 0(Q j j00(e j
Date last accuracy tested e- 0- / 1
Certified Tester )Oe kn Gn
Cert. Testa No. Ai0135yl Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy