2013_0502 (3)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE /
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: a�O� A.r .�.•
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer It Size y
Model Number �d"1 Located At SL C01 a
Serial Number
The above is certified to be true.
Firm Name A% Sk
Certified Tester
Firm Address 454% �40 Cert. Tester No.
.�►� Y "lttay4
Gauge # 0(e0`11' ,S Lf
Date last accuracy tested -1 1-2
r
Oo 1 —I Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
t
Tight
RP -psid
Leaked ❑
Leaked ❑
►�
psid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name A% Sk
Certified Tester
Firm Address 454% �40 Cert. Tester No.
.�►� Y "lttay4
Gauge # 0(e0`11' ,S Lf
Date last accuracy tested -1 1-2
r
Oo 1 —I Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy