2012_0907 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9
LOCATION OF SERVICE: 6 d l -5
The backt1ow 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 El Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
m.uf=,,,, Size 3/1-1
Model Number Located At Co t -r
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
I st Check- 2nd Check- Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Tight ❑ 0❑ Opened at Opened at
Tight ❑ Leaked ❑ ---Psid ------Psid
RP-----paid
Leaked ❑ Did not Open ❑ Leaked ❑
and
Repairs
A)c—c,d J14e, Materials CA �j
Used 3/,/ 64/t ()acv
Test After DC-Closed Closed Tight ❑ Opened at Opened atsid
Repair Tight ❑ psid ....... psid
RPLsid
The above is certified to be true. V-e 6
Firm Name A e- -'Y)c, -J Sk -e- Certified Testa
Firm Address PD &>)( -7'j'-7 Curt. Testa No. Q0091135--Date
PO- N -, V, a, 6 V-C
Gauge# 0309dV8
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy