2012_0906 (3)CHECK ONE:
IRRIGATION 4Q DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 4
LOCATION OF SERVICE: (�
Z, c,,qc t
The backflo\&, prevention assembly detailed belokv 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
❑ Pressure Vacuum Breaker
40 Double Check Valve
❑ Atmosphere Vacuum Breaker
01
Manufacturer f it,
U
size
Model Number 9 so
Located At N r x
Serial Number 14 c))Clltd
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
asid
Tiek to
Leaked
0
Bsid
Sid
RP- j—,e--psid
Leaked
Did not Open 0
Leaked C31
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight
C3
Opened at
Opened at
–psid
Repair
Tight
psid
_____--psid
RP sid
The above is certified to be true. q tS
Firm Name A4 -rin A/ ('tire,
Certified Tester I tAj 6-1 v% -A
Firm Address PO �O X '7 g
-0
Cert. Tester No. OOOJ'/-)Jr Date
ZTP kn -z e- -%
Gauge # OSO,9 Jc/g
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy