2013_0322CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L t 'T '% e' (— C-`7 O
PWS
LOCATION OF SERVICE: :i11/0 Q t V cl e
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
regLIlations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
go Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer rt""t � Size A9
�
Model Number '-( 0c. M Located At
Serial Number N o o d l
The above is certified to be true. a,5
Firm Name & `Y u.J (► ✓�
Firm Address L Ge) i
Gauge # 0 31-0— a icy
Date last accuracy tested 21
Certified Tester L VJ C -q yr z
Cat Tester No. CLO `l 'a` Date 3 /JJI)3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
Ist Check:
2nd Check:
Initial Test
(G' L
DC- Closed
Tight 3 C7 ❑
RP- �trSid
Closed Tight O
Leaked
Opened at
osid
Opened at
osid
psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
,osid
Opened at
osid
_osid
RP sid
The above is certified to be true. a,5
Firm Name & `Y u.J (► ✓�
Firm Address L Ge) i
Gauge # 0 31-0— a icy
Date last accuracy tested 21
Certified Tester L VJ C -q yr z
Cat Tester No. CLO `l 'a` Date 3 /JJI)3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy