2012_0420COTPELL
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # �I /
LOCATION OF SERVICE: Ll Pet2�c�,' <<t,
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
Double Check Valve
manufacturer LAo
Model Number :' ) Z) "
Serial Number WO/ / 3
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size `
Located At 61C Pte L a
The above is certified to be true.
Firm Name 1- A Fire & Domestic Testing
Firm Address P.O.Box 79548 Ft Worth Tx
Gauge # 06070576
Date last accuracy tested 12/01/2011
Certified Testa Brian Wagoner
Cat Tester No.BP0006562 Date 4 L U /Z_
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
O s` S
Tight
RP- - f P sid
Leaked c j ❑
osid
_osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 1- A Fire & Domestic Testing
Firm Address P.O.Box 79548 Ft Worth Tx
Gauge # 06070576
Date last accuracy tested 12/01/2011
Certified Testa Brian Wagoner
Cat Tester No.BP0006562 Date 4 L U /Z_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy