2012_0724 (5)CHECK ONE:
IRRIGATION- DOMESTIC
FIRELINE 1
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9 11 4,V 17 o i., C
LOCATION OF SERVICE:. go � 1 � H 2-,c) c
The backilow- prevention assembly detailed below has been tested and maintained as required by TCEQ
rc"Lliations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Press= Principle C Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer F4 L-0 Size
Model Number Located At 14-
Serial Number
REDUCED PRESSURE PRINCIPLE ASSENIBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 2nd Check- Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Tight Opened at Opened at nsid
Ti6t )a Leaked ❑ -- Sid Sid
Ri---_--psid I.?- —p
Leaked Did not Open C: Leaked C3
Repairs
and
Materials
Used
Test After DC-Closed Closed Tight 0 Opened at Opened at psid
Repair Tight 0 psid psid
---_PS id
The above is certified to be true.
Firm Name CertifiedTest= JaSOU, LS-7-OA)
Firm Address /0 Z97 A001 Q� Y/ Date-
�2,116, Cert Tester No.
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Gauge
I)ate last accuracy tested...,,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy