2012_0522CIIECK ONE:
IRRIGATION [2_ DOMESTIC_[]_ FIRELINE___Z_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS, Li7
PWS I.D. #
LOCATION OF SERVICE: 106 N. Denton Tap Rd.
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
HV( Double Check Valve H Atmosphere Vacuum Breaker
Manufacturer Hersey size
Model Number DC
Serial Number 182385
3/4"
Located At Vault on SE corner
The above is certified to be true.
Firm Name Action Fire Pros
Firm Address PO Box 797 Waxahachie
Gauge # 07090476
Date last accuracy tested 9 -21 -11
Allen Stevens
Certified Tester
Cat Tester No BP0009860 Date 5-22-12
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
Tight
Tight F
RP- 2—)&—psidr
Leaked
Closed Tight
Leaked E
Opened at
sid
Opened at
sid
Did not Open 0
---psid
Leaked
Repairs
11 and
Materials
Used
Test After
Repair
DC-Closed
Tight C
RP sid
Closed Tight C
Opened at
Psid
Opened at
sid,
nsid
The above is certified to be true.
Firm Name Action Fire Pros
Firm Address PO Box 797 Waxahachie
Gauge # 07090476
Date last accuracy tested 9 -21 -11
Allen Stevens
Certified Tester
Cat Tester No BP0009860 Date 5-22-12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy