2012_0906CHECK ONE:
IRRIGATION DOMESTIC K FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: (Cj2-i3,a
PWS I.D. #
LOCATION OF SERVICE:
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
Manufacturer - T -T size a
Model Number 00-7 Y") Located At A), �O)d
Serial Number A 116 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
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 du
Opened at
Opened at
--psid
DA 6 5
Tight � 99
RP- psid
Leaked 0
09.0
psid
sid
Leaked ❑
Did not Open C3
Leaked C3
Repairs
and
Materials
Used
After
DC-Closed
Closed Tight C
Opened at
Opened at
---psid
ETest
RZcpaV'ff
Tight ❑
psid
nsid
RP....Esid
The above is certified to be true. Y-e
Firm Name .4 6 Ito J r, ' c — Certified Tester N Wc,4 4-r- W e:,^ �'
Firm Address PQ (SOX -792 Cat Test No. QM gelds Date W610
Gauge # 03040.0316?
Date last accuracy tested qW
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy