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2012_0628CHECK ONE: IRRIGATION FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: �, /.1 <,, onvict The back flow prevention assembly detailed below- has been tested and maintained as required by TCEQ regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker Double Check Valve ❑ Atmosphere Vacuum Breaker .r Manufacturer Size Model Number ®��© C Located At k f rp5' S c5 -i tj ► ► t Serial Number The above is certified to be true. Firm Name 4C- -'«,-J (� ✓ e Firm Address 00 SOX-797 0a,e0 v,cL' —t Gauge # U 3 p 0,� ) eg Date last accuracy tested Certified Tests ,L 0 0-1 v+ G W e - -,, Cat Testa No. Afocx -1d*1— Date v I Z. White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE :ASSEMBLY I PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Cheek: 2nd Check: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight ❑ Opened at Opened at psid Tight ❑ Leaked ❑ psid psid RP —psid Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and l Materials ( °� Used L' 4 c C( L 1 ( Test After DC- Closed CIosed Tight} Opened at Opened at nsid Repair Tight I. e f M I Lr psid nsid sid ' The above is certified to be true. Firm Name 4C- -'«,-J (� ✓ e Firm Address 00 SOX-797 0a,e0 v,cL' —t Gauge # U 3 p 0,� ) eg Date last accuracy tested Certified Tests ,L 0 0-1 v+ G W e - -,, Cat Testa No. Afocx -1d*1— Date v I Z. White - Customer's Copy Yellow - City Copy Pink - Tester's Copy