2013_0322 (4)CHECK ONE:
IRRIGATION DOMESTIC Xl
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: _ _ L, ? C'1 C_� L
PWS I.D. #
LOCATION OF SERVICE: cl �� 1._) 4 d 18 -eAJ
The back11mv prevention assembly detailed below has been tested and maintained as required by TCEQ
reUulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle C. Pressure Vacuum Breaker
y V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Lek T .7 5 Size
Model Number 0c> '7 IM i
Serial Number A S ,2 1,,g 9 J
M
Located At (ems M e- T `',r 0 '% 5 7V -r
The above is certified to be true. Y t S
Firm Name >4 C -�'(o j f7i /.
Firm Address PQ J$o ), 7 5 '7
W (" ioG tiI &e. V1,
Gauge # ac21 - 1) J
Date last accuracy tested 3P3
Certified Tester g, Y% V% el'
Cat. Testa No. QM C ` Date _35 IdO fi
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
' PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check —T-2nd
Check
Relief Valve
Air Inlet
Check Valve
Initial Test
PA
DC- Closed
Tight �. ��
RP- pSid
Closed Tight .isG'
Leaked U ❑
Opened at
psid
Opened at
psid
psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
RP
RP sid
Closed Tight ❑
Opened at
Sid
Opened at
_i nsid
� Sid
The above is certified to be true. Y t S
Firm Name >4 C -�'(o j f7i /.
Firm Address PQ J$o ), 7 5 '7
W (" ioG tiI &e. V1,
Gauge # ac21 - 1) J
Date last accuracy tested 3P3
Certified Tester g, Y% V% el'
Cat. Testa No. QM C ` Date _35 IdO fi
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy