2013_0322 (3)CHECK ONE:
IRRIGATION DOMESTIC N
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MA MNANCE REPORT
NAME OFPWS: L t ?`/ GAF c.11Or�t
PWS I.D. #
LOCATION OF SERVICE: _sue G/ o �S t V i c4-e ✓F d
The backilow 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 w Pressure Vacuum Breaker
i Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer wc, �-t S Size j
Model Number 00 ) 01 1
Serial Number A 9 b6 -&-it
Located At 19L0e -rc-- C-'AJ S i12ec _`
The above is certified to be true. ytS
Firm Name Al .n0 .,! Certified Tester L W'� -t ^� �- -e Y% vN
First Address lhx 7'5 `7 Ccrt. Tester No. ow q ,-Q T Date 31ddH
f'1J�C_ i�7G3 ►n GY'%1. �
Gauge # f�1 -D I �
Date last accuracy tested--31 fJ
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI IBLY
PRESSURE VACUUM BREAKER
Double Check valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
�
Opened at
Opened at
�
()A4
Tight '_
RP- �" -Ps-
id
Leaked IS
❑
nsid
nsid
_nsid
Leaked ❑
Did not Open
o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight
o
Opened at
Opened at
nsid
Repair
Tight o
nsid
_� Sid
RP sid
The above is certified to be true. ytS
Firm Name Al .n0 .,! Certified Tester L W'� -t ^� �- -e Y% vN
First Address lhx 7'5 `7 Ccrt. Tester No. ow q ,-Q T Date 31ddH
f'1J�C_ i�7G3 ►n GY'%1. �
Gauge # f�1 -D I �
Date last accuracy tested--31 fJ
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy