2013_0708 (2)CIIECK ONE:
IRRIGATION X DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L, ?°
PWSI.D.9
BCDa
Iy4kcy<ttanct
I
LOCATION OF SERVICE:
'S . Ru-i cd L-N
-0 ton
2nd Check:
Relief Valve
The back1low prevention asse,nbly detailed belo.v has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSE]IvIBLY
17 Reduced Pressure Principle ❑ Pressure Vactum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufac=er r4-" Size Q u
Model Number 650 Located At l J N N--M't ?Q Lx-)y3
Serial Number 13110
The above is certified to be true.
Firm Name k-+k C o FIFE fiC n
Firm Address PC 61 c 717
w( I1 -vat` �q ( e_ TTj
Gauge # 2LJ1 -5
Certified Tester t n—, Q -IL)-S-r J
Cat Testa No. Date 7/81 /3
Date lust accuracy tested �/2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMMBLY
{ PRESSURE VACLZJM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed 2.q
Tilt
RP. _psid
Closed Tight ,N
Leaked 0
2.0
Opened at
Mid
Opened at
-- .��osid
_psid
Leaked ❑
Did not Open 0
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight ❑
,psid
,psid
P P sid
The above is certified to be true.
Firm Name k-+k C o FIFE fiC n
Firm Address PC 61 c 717
w( I1 -vat` �q ( e_ TTj
Gauge # 2LJ1 -5
Certified Tester t n—, Q -IL)-S-r J
Cat Testa No. Date 7/81 /3
Date lust accuracy tested �/2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy