2012_0907 (5)CHECK ONE:
IRRIGATION DOMESTIC V FIRELINE
BAC IGLOW PREVENTION ASSEMBLY TEST AND MAJ[NTENANCE REPORT
NAME OF PWS: ) o'a
PWS I.D. #
LOCATION OF SERVICE: G� 5- t` -c-'•/ c C
The backilow 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
o Reduced Pressure Principle 0 Pressure Vacuum Breaker
iD Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer w--- -v -15 Size (� j nn
Model Number ( c)'-I Wl r Q r Located At
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM qValve
Double Check Valve Assembly
Ist Check 2nd Check Relief Valve Air Inlet CheInitial Test DC- Closed Closed Tight iD Opened at Opened at �Tight 00, Leaked o nsid osid
Rp- i 1 `l Dsid Leaked Cl Did not Open 0 Leak
Reps
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at nsid
Repair Tight a nsid psid
RP id
The above is certified to be true.
Firm Name A t T iCoN '-Vrc- Certified Tester
Firm Address N) �)a X -7 9 7 Celt, Tester No. vpo °l 35- Date q /7
WC -)oa%A CCO I
Gauge # 030.909/8
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy