2012_1024CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
PWS I.D. #
C-b-PPE LL
LOCATION OF SERVICE: !r iY 7 S F+ { -2- j
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
C Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
FE E3 CC-) size
Model Number `J 0
Serial Number h" 3 -1 R g L
it
Located At T—^' �5/ w CvrUrt� --
OF }�2C�PU2'' /
The above is certified to be true.
Firm Name 4 f Iq Ae- i Ty r, AeAFt�`Certified Tester �
Firm Address (-fi )e- L bi�c iaa �--! '/)C-- 75crr'7 Cert. Tester No. W b b 133 1) w Date >D -- Z g -/ Z
Gauge # yng0 - f �
Date last accuracy tested
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
Opened at
Opened at
osid
-Pa
S5
Tight ❑
RP- .Z sid
Leaked ❑
Leaked C3
Z I
`�
psid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name 4 f Iq Ae- i Ty r, AeAFt�`Certified Tester �
Firm Address (-fi )e- L bi�c iaa �--! '/)C-- 75crr'7 Cert. Tester No. W b b 133 1) w Date >D -- Z g -/ Z
Gauge # yng0 - f �
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy