2013_0322 (2)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE J` &fczS
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L. r ? `/`
PWS I.D. #
LOCATION OF SERVICE: _,�lf0 Qt v 1 d e?�,, cl
The backf7ow 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
16 Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer We, '1.1 S Size '314
Model Number C217 e-4 Located At 1121 Y
Serial Number 1 b 1 ,;) C
The above is certified to be true.
Firm Name 6—r1Q ti t t' i 1-6 Certified Testa �tJa�:j NNe 1A) e -V\ v\ 6?,'
Firm Address _�� ) �, °7 ,> Celt Tester No. Cade 51"t) Date 3 /�j 11
Gauge # U -02-9 --)) It;
Date last accuracy tested 311 ?j
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
1st Check
2nd Check
Initial Test
DC- Closed
Tight ❑
,, 0
RP- r� Dsid
Closed Tight 0
Leaked J-011
Opened at
psid
Opened at
_ —psid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
i_nsid
Opened at
nsid
_ nsid
RP sid
The above is certified to be true.
Firm Name 6—r1Q ti t t' i 1-6 Certified Testa �tJa�:j NNe 1A) e -V\ v\ 6?,'
Firm Address _�� ) �, °7 ,> Celt Tester No. Cade 51"t) Date 3 /�j 11
Gauge # U -02-9 --)) It;
Date last accuracy tested 311 ?j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy