2013_0405CIIECE ONE:
IRRIGATION DOMESTIC FIRELINE A4Ci ,/ z t.tiz
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: v?11 y D c✓ 1 d e." d
The back low 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
C Reduced Pressure Principle L Pressure Vacuum Breaker
IV Double Check Valve L) c (3 4 ❑ Atmosphere Vacuum Breaker
Manufacturer Size /0
Model Number -77 `/ be p,,4- Located At fx)(.,) ?-, J.M,r��
Serial Number
The above is certified to be true.
Firm Name AG �� J �✓
Firm Address &:- f�>c X 7X17
tk )C sc C yic: .� �.
Gauge # ><<'
Date last accuracy tested / / 3
Certified Tester I_ _1 UJ c %,&� 1,-J t +,. 0 rr
Cent. Tester No. QQ,-� �l�� ^ Date -16-11,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEIM3LY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 7772ndCheck-
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
Dsid
ti
Tight b
RP -,s � Dsid
Leaked]
AeJ
psid
j)sid
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
C; K G
Test After
DC- Closed
Closed Tight
Opened at
Opened at
_ osid
Repair
Tight 3 c) 91
`3
-- --Dsid
nsid
Sad
The above is certified to be true.
Firm Name AG �� J �✓
Firm Address &:- f�>c X 7X17
tk )C sc C yic: .� �.
Gauge # ><<'
Date last accuracy tested / / 3
Certified Tester I_ _1 UJ c %,&� 1,-J t +,. 0 rr
Cent. Tester No. QQ,-� �l�� ^ Date -16-11,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy