2013_0919 (4)CIIECk ONE:
IRRIGATION`S
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer iA Size 1
Model Number b "J Located At 1 oj yl Y1avibn (j—f.- v,.P iv,
&
Serial Number A 0 o D-� ,-3 fyrjv-e--�
The above is certified to be true.
Firm Name 1)0,-tj9l e� D Certified Tester -A-Aam Lze-"
Firm Address P�CX ;LIa ELYW'. lY* Cert. Testa No.NQ� Date lei Is
� 7SS7 2�
Gauge # 7
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
osid
Tight ❑
Leaked
nsid
osid
RP -_psid
Leaked
Did not Open ❑
Leaked ❑
Reps
ge,'9 CerA
plC c'
and
Materials
Used
Test After
Repair
DC- Closed
Tight .
RP psid
Closed Tight to
Opened at
nsid
Opened at
osid
vsid
The above is certified to be true.
Firm Name 1)0,-tj9l e� D Certified Tester -A-Aam Lze-"
Firm Address P�CX ;LIa ELYW'. lY* Cert. Testa No.NQ� Date lei Is
� 7SS7 2�
Gauge # 7
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy