Loading...
2012_0522CHECK LINE: Z1 DOMESTIC; X FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: _ L ,-T , e) r PWS I.D. # LOCATION OF SERVICE: (0o I S. k 4 ) The back flow prevention assembly detailed below has been tested and maintained as required by TCEQ rc,�ulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C Reduced Pressure Principle C Pressure Vacuum Breaker Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacture. _ wo 45 Size Model Number 00 -7M I Serial Number 61 � 33 2 Located At a' m 4-tr The above is certified to be true. Firm Name "o n 9k 2E P CA Ccrtified Tester �6 pbo l o (,,S 1 Firm Address Po F3 '7�"Z .W ���a two i-h �C Cert Tester No. 01,S0-1 �S�°Date 22 12- 7-x Gauge # n_C2 I I ©0%= Date last accuracy tested cI1 !�?' i I White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Doable Check Valve Assembly 1st Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight Opened at Opened at osid Tight RP -osid Leaked ❑ psid osid j Leaked ❑ Did not Open ❑ Leaked ❑ ' Repairs and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at osid Repair Tight ❑ osid osid RP sid The above is certified to be true. Firm Name "o n 9k 2E P CA Ccrtified Tester �6 pbo l o (,,S 1 Firm Address Po F3 '7�"Z .W ���a two i-h �C Cert Tester No. 01,S0-1 �S�°Date 22 12- 7-x Gauge # n_C2 I I ©0%= Date last accuracy tested cI1 !�?' i I White - Customer's Copy Yellow - City Copy Pink - Tester's Copy