2013_0514 (2)CIIECK ONE: /
IRRIGATION ✓
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C'• �t]�p �� L
PWS I.D. #
LOCATION OF SERVICE:
I � 8 4 5 • -tv+V, v„e,
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 W �I \:��\Y\5
Model Number 350
Serial Number N a 4 Za Ja �(e
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 1 1I�
Located At 5 F Cc rn Y 1- �
The above is certified to be true.
/� �/rr 6t 41v*
Film Name HI 1 1 �5'� Certified Tester y
Firm Address L54tf Q4 aOJI Ila Cert. Tester No. N0010IM 05 Date 5-114-13
ZY
Gauge # 0007 /7 N
Date last accuracy tested 7-1(0 • /;L
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
Tight a,a X
Closed Tight )-
Leaked ❑
Opened at
psid
Opened at
oSid
oSid
aS 5
RP- ,__psid
Leaked ❑
(9 (o
Did not Open ❑
Leaked Cl
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
oSid
RP psid
The above is certified to be true.
/� �/rr 6t 41v*
Film Name HI 1 1 �5'� Certified Tester y
Firm Address L54tf Q4 aOJI Ila Cert. Tester No. N0010IM 05 Date 5-114-13
ZY
Gauge # 0007 /7 N
Date last accuracy tested 7-1(0 • /;L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy