2012_0724 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE___�,/
BA OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PPS I.D. 9
LOCATION OF SERVICE:, bli
Lao_
The backilow Prevention assembly detailed below has been tested and maintained as required by TCEQ
reutilations and is certified to he operating within acceptable parameters.
t2
ME OF ASSEMBLY
0 Reduced Pressure Princile C Pressure Vacuum Breaker
0 Double Check Valve 0 Atmosphere Vacuum Breaker
Manufactures 1.6- e- (9 Size
B fl
Model Number 8540 Located At AJc*��q,kLc.
14
Serial Number k1A-T LFjQlbL8'
I.";
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B-R—EA—K-ER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check-
2nd Check-
Initial Test
DC-Closed 2 c
Closed Tight
Opened at
Opened at
osid
Tight
Leaked ❑
psid
nsid
RP------psid
Leaked C
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight C3
Opened at
Opened at
nsid
Repair
Tight
Psid
sid
RP======2sid
The above is certified to be true.
Firm Name Ac4 ov, f7l!:te &C CerdfiedTe= -,
JaSOv
.L _
Firm Address 1% 62,V :Z q] --- Cart. Tester No. OffiQlQE22 Date 2�2--42
W c� >c t' k A- C- V(v -rx
Gauge # I /
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy