2013_0225 (2)CHECK ONE:
IRRIGATION ✓
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ; - u n-�,
PWS I.D. #
LOCATION OF SERVICE:
in
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
[9 Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 10 R+ Size 1;4`,
TM
Model Number 00.7 1 A \ Q T Located At Pt t 1 i1L-' tl L'oe=- t `�Kd <2, +
�L
Serial Number 1 7 7. 3
The above is certified to be true.
Firm Name 0 S ,_-,(.�- ertified Tester f 'wit �'t i
Firm Address '` ` % 1" Cart. Taster No. PC , Date 13
Gauge #
Date last accuracy tested
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
f Air Inlet
Check Valve
Initial Test
DC- CIosed
Closed Tight
Opened at
Opened at
nsid
Tight
Leaked ❑
psid
nsid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name 0 S ,_-,(.�- ertified Tester f 'wit �'t i
Firm Address '` ` % 1" Cart. Taster No. PC , Date 13
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy