2012_0724 (6)CHECK ONE
IRRIGATION---- DOMESTIC FIRELINE x
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9
LOCATION OF SERVICE: e c o
The backl1mv prevention assembly detailed beloxv has been tested and maintained as required by TCEQ
regulations and is certified to be operatint., within acceptable parameters.
TYPE OF ASSEMBLY
0 Reduced Pressure Principle 0 Pressure Vacuum Breaker
Double Check- Valve 0 Atmosphere Vacuum Breaker
Manufacturer fa- 0 size
Model Number s Located At u6
Serial Number 070 2 2 Le I
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check L2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Tight X Opened at Opened at nsid
Tight Leaked 13 psid sid
RP----.psid 5,
Leaked C Did not Open 0 Leaked 13
Repairs
and
Materials
Used
I
Test After DC-Closed Closed Tight C] Opened at Opened at sid
Repair Tight a nsid psid
R-P=====2std
The above is certified to be true.
Firm Name ZzLla Lta E -Plfa) Certified Tester Lsm),J
Firm Ad&dedZ --� '-7 Cent. Tester No. Date 7/e- 2
ujc',,/w a-, V�
Gauge # -&l L Q O 75
Date la q 11
last accuracy tested 5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy