2012_0906 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE )0 $-,1 ?, f
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: LCI 62 0,= z
PWS I.D. #
LOCATION Of SERVICE: yajt
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
C
Reduced Pressure Principle
C Pressure Vacuum Breaker
pj
Double Check Valve
C Atmosphere Vacuum Breaker
M..f=.U,,
size
Model Number 00 7 a
Located At )J, L- V0,UL
Serial Number b (9 1)0
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
Opened at
Opened at
...... psid
P�3
Tight tP
Ri- 1- (9 psid
Leaked
sid
-----psid
Leaked C
Did not Open o
Leaked
Repairs
and
Materials
used
Test After
DC-Closed
Closed Tight
C3
Opened at
Opened at
psid
Repair
Tight
psid
txsid
RP=,==,Zsid
:MUMMMIMMMMM
�
The above is certified to be true.
Firm Name A Lrt a J Certified Tester
Firm Address
Cat Tester No. 0009 t1 Date
0C;,-)CC, AA c C 4 r
Gauge # 0 3 off' J 9( H
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy