2012_0907 (2)CHECK ONE
IRRIGATION FIRELINE
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BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 2 0 ,(z
PWS I.D.
LOCATION OF SERVICE: L
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 0 Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
y 11
Manufacturer �c 7-7 size J
Model Number 00 7- M I Located At Aj � w Or pL),UNj�4
Serial Number So
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BIR—EA-K-ER.
Double Check Valve Assembly
Ist Check tad Check- Relief V21VIe Air Inlet Check Valve
Initial Test DC-Closed Closed Tight ❑ Opened at Opened at -Psid
T161 ❑ Leaked C3 ----__psid sid
t- U----psid
Leaked ❑ Did not Open u Leaked ❑
Repairs
and
Materials (A J -IJ 0
Used
Test After DC-Closed Closed Tight C3 Opened at Opened at --j)sid
Repair Tight ❑ psid ysid
RP....asid
The above is certified to be true.
Firm Name A-6 -C I J-J Certified Tester Wr -i v1 c- Wn f/
Firm Address PO '�'0,1< -7 '1 `7 Cat Tester No. QW514)5 Date —c?/
joa,<a V% C: (- il% -
Gauge# 0,3083D1,§
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy