2013_0423CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Lo4p 't
PWS I.D. # p
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.
TYPE OF ASSEMBLY
� Reduced Pressure Principle ❑ Pressure Vacuum Breaker
'4k Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturers
Model Number
Serial Number J-W qq Ll
Size
f
The above is certified to be true.
Firm Name Certified Testa
' 0
Firm Add�r-e -s-s�� �� -BC�a# T No. Date -
-= v 76,
Gauge #1 /000VC>:Z
Date last accuracy tested 2�—
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 -Cln
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
n sid
nsid
RP -_,psI
Leaked
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test Auer
DC- Closed (•
Closed Tight
Opened at
Opened at
nsid
Repair
Tight
RP sId
1-7
nsid
nsid
The above is certified to be true.
Firm Name Certified Testa
' 0
Firm Add�r-e -s-s�� �� -BC�a# T No. Date -
-= v 76,
Gauge #1 /000VC>:Z
Date last accuracy tested 2�—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy