2012_0111 (4)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Old co we
PWS I.D. # Q n/ �1 �1 9 f 1_
LOCATION OF SERVICE: U 51 / V l a-- A- Aur 131,,J- k� o L j /e q
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
.2K
Double Check Valve
F &:Cj
Manufacturer
Model Number
TJ '50
Serial Number
-
t1 19. 1 1
TYPE OF ASSEMBLY
❑ Pressure Vacui n Breaker
❑ Atmosphere Vacuum Breaker
Size
2''
Located At I'l.,5f
The above is certified to be true.
Firm Name _ 4l+l 1 ob/ l
Firm Address qSq8 Ab-Jr) c.1e Wai
Gauge # 0001 ICj(j G 9
Date last accuracy tested
Certified Tester Alko
Cert. Testa No. y I Date 1 /I -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
f&,J
DC- Closed
Tight a
RP- / psid
Leaked ❑
Closed Tight K
Leaked ❑
/8
Opened at
psid
Opened at
_ ^nsid
Did not Open ❑
psid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
_psid
Opened at
psid
n sid
RP sid
The above is certified to be true.
Firm Name _ 4l+l 1 ob/ l
Firm Address qSq8 Ab-Jr) c.1e Wai
Gauge # 0001 ICj(j G 9
Date last accuracy tested
Certified Tester Alko
Cert. Testa No. y I Date 1 /I -12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy