2013_0225CHECK ONE:
IRRIGATION /
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C; ft-/n-F, C J_ no e_ i I
PWS I.D. #
LOCATION OF SERVICE: C ✓ eOo'�' t"
The backflow 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
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer LL),f-)[ �� Size
IN
Model Number 0 7 `3C7 Located At meted ( � �,��✓`f
Serial Number 1 q 7 _Fi
The above is certified to be true.
Firm Name ` `- � C crtified Testa
Firm Address LE it s �5 �'r 1 LAC 7_ � < `� Cert. Testa No.
Gauge # _0,� 10,) L%51
Date last accuracy tested ;,__� -- (— I,;)-
f-ev en
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
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
psid
Tight
Leaked ❑
psid
psid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight o
psid
psid
RP sid
The above is certified to be true.
Firm Name ` `- � C crtified Testa
Firm Address LE it s �5 �'r 1 LAC 7_ � < `� Cert. Testa No.
Gauge # _0,� 10,) L%51
Date last accuracy tested ;,__� -- (— I,;)-
f-ev en
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy