2013_0919 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW�I PREVENTION (ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: St, Mm E, (;d&
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
a Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �« Size �-
Model Number Located At Na--,
Serial Number -T
The above is certified to be true.
Firm Name f �e e, Certified Tester Adam L�-
Firm Address : X S FtJf �� f (Cem Tester No f- 9 L— Date ✓
�2S`Y2 to
Gauge # j � 3q 9 L-
Date last accuracy tested—L-2 4
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
nSid
osid
RP -_psid
Leaked
Did not Open ❑
Leaked ❑
Repairs
1 r iaadc
Q
and
Materialst
Used
Test After
Repair
DC- Closed
Tight') - �- s'
Closed Tight
r
Opened at
Sid
Opened at
Sid
_nSid
The above is certified to be true.
Firm Name f �e e, Certified Tester Adam L�-
Firm Address : X S FtJf �� f (Cem Tester No f- 9 L— Date ✓
�2S`Y2 to
Gauge # j � 3q 9 L-
Date last accuracy tested—L-2 4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy