2013_0919 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C n � fdAb
PWS I.D. #
LOCATION OF SERVICE: ! t, M — j I l E, ► �_ IBC .
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
ar Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 1 Size
Model Number () (D] M i
Serial Number 5 V13 9
M
Located At71C,[!�
The above is certified to be true.
Firm Name )OU l e- 'b R (tZ Certified Tester AAAM Le
Firm Address i �o��a ��j°►�2 ` j�C Cert. Tester No.0 Date 9
Gauge # G
Date last accuracy tested
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
nsid
Tight ❑
Leaked all,
sid
nsid
RP -_psid
Leaked
Did not Open ❑
Leaked ❑
Repairs
it�r,CQ_C�
and
MaterialsApor1a
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-"k
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Used
-
R
Test After
DC- Closed
Closed Tight
Opened at
Opened at
nsid
Repair
Tight- t2r
nsid
nsid
The above is certified to be true.
Firm Name )OU l e- 'b R (tZ Certified Tester AAAM Le
Firm Address i �o��a ��j°►�2 ` j�C Cert. Tester No.0 Date 9
Gauge # G
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy