2012_0724CHECK ONE:
11tRIGATJON_/'C DOMESTIC- r FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NANE OF PWS:
PWS I.D, 4
LOCATION OF SERVICE..
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
reoulations and is certified to be operating, within acceptable parameters.
TYPE OF ASSENSLY
C Reduced Pressure Principle 0 Pressure Vacuum Breaker
/k Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer n7 ko Size ez it
6 r-
Model Number Located At AIZ4 /q- ulk-)
Serial Number
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'Z. ✓ Closed Tight X Opened at Opened at --- psid
Tight Leaked psid psid
RP------psid
Leaked ❑ Did not Open 0 Leaked C3
Repairs
and
Materials
Used
Test After DC-Closed Closed Tight C3 Opened at Opened at Sid
Repair Tight o psid nsid
RP sid
The above is certified to be true.
Firm Name -A i mr) � EL- Of (D Certified Test= 03,:2Dn
Firm Address a &-,,/ 7-2 7' Cat Tester No. U?j=i Ck-,C, I Date -1
kXc, kc, I.,U T f
Gauge -# X11
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy