2013_0502CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE /
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 0 Aw 2� COOOA ,1
PWS I.D. #
LOCATION OF SERVICE: X0`-1 A:r 1k,
The backtlow 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
V Reduced Pressure Principle El Pressure Vacuum Breaker
Double1}Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer V30,lk Size t
Model Number -101 Dp hp Located At 5t (N_ ,o rna 04 \?+►+ti�T
Serial Number WWII
The above is certified to be true.
Firm Name E `\ -S�
Firm Address N)14-4.101
Gauge # 0(#01l')YLt
Date last accuracy tested 1 1114 11
Certified Tester 1'�`
Cent. Tests No. V0014-11U Date S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
uSid
P ^55
Tight
RP- I.4 Dsid
Leaked ❑
Leaked ❑
psid
pSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight ❑
Opened at
Opened at
pSid
Repair
Tight ❑
psid
vSid
RP sid
The above is certified to be true.
Firm Name E `\ -S�
Firm Address N)14-4.101
Gauge # 0(#01l')YLt
Date last accuracy tested 1 1114 11
Certified Tester 1'�`
Cent. Tests No. V0014-11U Date S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy