2012_0724 (2)CHECK ONE:
IRRIGATION-_ DOMESTIC- FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9
LOCATION OF SERVICE: h] _tv2oo
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
rem0ations 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 F7e, � & 0 Size 2a
Model Number 85 (0 - Located At Alb Z-44, U& U 4--
Serial Number ALI: 1409Le-
PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check Relief Valve Air Inlet Check Valve
Closed Tia-hit
Initial Test DC- Closed Opened at Opened at osid
Tight Leaked ❑ psid ______psid
Ri-____psid
Leaked c Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used
Test After DC-Closed Closed Tight ❑ Opened at Opened at psid
Repair Tight ❑ psid nsid
RP-----vsid I
The above is certified to be true.
Firm Name A �2n E1(2t C2 c) Cat ffiedTe= k)0_Scy,
Firm .Address ffi L c -7q:Z Ccrt. Test= No. RP601 N,5- I Date
Gauge
Date Jas accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy