2012_0907CHECK ONE:
IRRIGATION ?C DOMESTIC
FIRELINE
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS. ( *'T',1 e E Lc, 12- 12 -- /Z
PWS I.D. # nn
LOCATION OF SERVICE: A d l 6, (Zoyc 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.
TYPE OF ASSEMBLY
0
Reduced Pressure Principle
0 Pressure Vacuum Breaker
W
Double Check Valve
❑ Atmosphere Vacuum Breaker
Manufacturer
rv-- 'cl C 0
Size d
Model Number cg
Located At �C)ca NO)c Ucorr
Serial Number A o-76a
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Closed Tight
❑
Opened at
Opened at
nsid
�A
Tight (F►
RP- j—,Lpsid
Leaked
Ob
------psid
nsid
Lzaked ❑
Did not Open ❑
Leak-ad ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight
❑
Opened at
Opened at
esid
Repair
Tight ❑
-----psid
______psid
I
RP=====Mid
The above is certified to be true. y � 5
i-
0—
Firm Name ,4 e -T ►6 --) I /'c Certified Tester W c -Vf-
Rim Address P0 (L-1G Y, I 5 Cent Tester No. 000 1 051 , Date
W C', e, C- K C C. 0r—
Gauge # 0306 z9,9160
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy