2013_0708CHECK ONE:
IRRIGATION X DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: r.? `l e i
PWS I.D. 9 K t T y1£t }
LOCATION OF SERVICE:e,
The backllow , prevention assemble detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSE.NiBLY
M Reduced Pressure Principle M. Pressure Vacuum Breaker
X� Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer ,- .2k'C.�_ Size 46
Model Number 656 Located At 5,oym Va u #
Serial Number 026- 71214?/, _.
The above is certified to be true.
Firm Name �C +_ C h r 1 u90.4
Firm Address PC &J 7
WCW, V2 tC_ Ty
Gauge # Uri i� 315
Date last accuracy tested
Certified Testtr �6)0 '0-v rc�
Cent Testa No. 3Pc 66 ;1 Dam 2IM4L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ezlwv
1st Check
2nd Check
C
Relief Valve
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opmed at
Opened at
_ —,nsid
Tight ❑
Leaked ❑
psid
„r flSid
RP- __,____psid
ti
Leaked o
Did not Open ❑
Leaked ❑
Repairs -T
I and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
_,._._..,vsid
Opened at
gsid
_ T sid
1.
Rp sid
The above is certified to be true.
Firm Name �C +_ C h r 1 u90.4
Firm Address PC &J 7
WCW, V2 tC_ Ty
Gauge # Uri i� 315
Date last accuracy tested
Certified Testtr �6)0 '0-v rc�
Cent Testa No. 3Pc 66 ;1 Dam 2IM4L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy