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2013_0502 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ regulations and is certified to be operating within acceptable parameters. Reduced Pressure Principle Double Check Valve Manufacturer �w Ak Model Number ©O" 1 W\ Serial Number 04121 TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size Located At 5t—: Carnes o� The above is ed to be true. Firm Name Certified Tester Firm Address 45% Cat Testa No. Gauge # 0(.0-)11gq Date last accuracy tested White - Customer's Copy T -L \LJ4 Vm\ �-1 if, Date Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Check: 2nd Check: 'ef Valve Air Inlet Check. Valve Initial Test DC- Closed Closed Tight Opened at Opened at psid h55 Tight RP- I A sid Leaked ❑ Leaked ❑ �' psid osid Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at psid Repair Tight ❑ psid osid RP sid The above is ed to be true. Firm Name Certified Tester Firm Address 45% Cat Testa No. Gauge # 0(.0-)11gq Date last accuracy tested White - Customer's Copy T -L \LJ4 Vm\ �-1 if, Date Yellow - City Copy Pink - Tester's Copy