2012_0906 (2)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE_ ,.;;,J
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: j-2 4) , I/
PWS I.D.
LOCATION OF SERVICE:. 3
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
0 Reduced Pressure Principle 0 Pressure Vacuum Breaker
P Double Check Valve 0 Atmosphere Vacuum Breal=
Manufacturer wo-7 -1 5 size CC?
Model Number 771-) 66 OA Located At 1j, L vov 1,
Serial Number 1100-P-10 d(z,
REDUCED PRESSURE PRINCIPLE ASSEINIBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
I st Check 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Tight $P Opened at Opened at nsid
Tight W Leaked 3. j C3 sid sid
Rj- sid
Leaked 0 Did not Open C3 Leak-ad C3
;7ai—rs
and
Materials
Used
Test After DC-Closed Closed Tight C3 Opened at Opened at ---psid
Repair Tight 0 --psid --psid
FP=====2sid
The above is certified to be true. y,-!)
Firm Name AC 2-10,41 -t/y— Certified Taw 11-t Y, t Iti A -yn e-
Firm Address 00 ('C>X :Z 'I Cart Tester No. Q-W 7 4 ol'S- Due
Id C Y c, V--c, C 1% -
Gauge # 6 3p8 9 J�
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy