2013_0514CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
PWS I.D. #
LOCATION OF SERVICE: Qui k -Tr l e 4 Rit9
iy8L4 S• 6e-4V v— PEJ
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer (A) I 1 k i v1 S
Model Number 35a
Serial Number 61 514 23(p
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size ` /2
Located At 5L Co rn•Pr- Cam_
The above is certified to be true.
Firm Name g// Certified Tester : /e r 4V/ 4 n
Firm Address 44fT /y- k.,e Cert. Testa No. 6*01 *905 Date 5 %3
Gauge # 6)& of f 7 �y
Date last accuracy tested 7 /& `/-Z-
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
5
DC- Closed
Tight _I,q
RP--f psid
Leaked ❑
Closed Tight tai
Leaked ❑
Opened at
psid
Opened at
Dsid
Did not Open ❑
Dsid
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Dsid
Repair
Tight ❑
Dsid
Dsid
RP sid
The above is certified to be true.
Firm Name g// Certified Tester : /e r 4V/ 4 n
Firm Address 44fT /y- k.,e Cert. Testa No. 6*01 *905 Date 5 %3
Gauge # 6)& of f 7 �y
Date last accuracy tested 7 /& `/-Z-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy