2012_0907 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE )(* vtAz,J
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS1-
PWS I.D. #
LOCATION OF SERVICE:
The back flow prevention assembly detailed below has been tested and maintained as required by TCEQ
rec,ulations and is certified to be operating within acceptable parameters.
o Reduced Pressure Principle
Double Check Valve
Manufacturer e 1 t --X
Model Number
serial Number Coo -/ 3 k 4
TYPE OF ASSEMBLY
El Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
1? 1,
Size
C
Located At ,J. C On 0 i --r-
The above is certified to be true. q z �
Firm Name Az -1-10,,) r r <-
Firm Address
Gauge# 0
Date last accuracy tested
Certified Tester �) W04 Y, C W& -%,,, e"
Cert. Testa No. 0Q0if-125"- Due 917)12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
I st Check-
2nd Check-
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Closed Tight
V)
Opened at
Opened at
J)s d
Tight_, 11
Leaked
C)
P sid
sid
ti 5
RP- , sid
-3,
Leaked C
Did not Open C3
Leaked C3
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight
C3
Opened at
Opened at
—__--psid
Repair
Tight C]
psid
Sid
RP==--r gsid
The above is certified to be true. q z �
Firm Name Az -1-10,,) r r <-
Firm Address
Gauge# 0
Date last accuracy tested
Certified Tester �) W04 Y, C W& -%,,, e"
Cert. Testa No. 0Q0if-125"- Due 917)12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy