2013_0614J
CHECK ONE:
IRRIGATION DOMESTIC �ODI , ` FIRELINE
Po- 13 -�vz�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
1
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
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.
a / Reduced Pressure Principle
Double Check Valve
Manufacturer.0��0 --
Model Number $50
Serial Number k 3IOS�oI
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
k
Size
Located At 'Al M as `QA V �
The above is ed to be true.
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Firm Name Certified Tester
Firm Address qS4 f ."w, OILV-w1k Cat Tester No.
. UPo
Gauge # Q60-11114
Date last accuracy tested , I
Date 1
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
Ti
Closed Tight ❑
Leaked
Opened at
psid
Opened at
osid
osid
h �1
ll .gsid
Leaked ❑
Did not Open ❑
Leaked ❑
and
QA op
Materials
Used
Test After
•
try
DC- Closed
Tigl�
RP �S U sad
Closed Tight
Opened at
osid
Opened at
osid
osid
The above is ed to be true.
r�
Firm Name Certified Tester
Firm Address qS4 f ."w, OILV-w1k Cat Tester No.
. UPo
Gauge # Q60-11114
Date last accuracy tested , I
Date 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy