2013_0919 (3)CIIECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: (,!A`�L LOW 12-W-,
PWS I.D. # 1-71-7
LOCATION OF SERVICE: St - �G 1 i —
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
},e'er Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Febco Size 1
Model Number J Q Located At
Serial Number 0 11
The above is certified to be true.
Firm Name e- Certified Tester Adam L",
Firm Address D c ^ t� Cert Tester Nod ) I Date
Gauge # � T �-
Date last accuracy tested j — aZ ^ 13
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
usid
Tight ❑
Leaked Le
usid
usid
RP -_psid,,,/
Leaked 1�
Did not Open ❑
Leaked ❑
p ans
(��
�rt
and
Materials
Used
cayg X�
Test After
DC- Closed
Closed Tight
Opened at
Opened at
usid
Repair
Tight -
1
nsid
usid
RP i - sid
The above is certified to be true.
Firm Name e- Certified Tester Adam L",
Firm Address D c ^ t� Cert Tester Nod ) I Date
Gauge # � T �-
Date last accuracy tested j — aZ ^ 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy