2013_0708 (3)CHEC K ONE..
IRRIGATION X
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Lii 17 1 -212
PWS I.D. 9 lLXAS I er 1.14i -t t� r� ri
LOCATION OF SERVICE: S -4 Zoo
The backllow 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
J Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer ��hC6 size 26� y
Model Number 656 Located At zVmli, In it f4
Serial Number C.C�4 44/
The above is certified to be true.
Firm Name &J t�Far- RoS
Firm Address L d9z III!7
( )a)C41LtczC.V1 to TjC
Gauge # Ofv 116015
Date last accuracy tested __.. q 5 2
Certified Tester JaS60 4(-),STco 0
Cert. Tester No. ao-X) G S 1 Date 46LL
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUTJM BREAKER
Double Check Valve Assembly
1st Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight
Leaked C '
� 9
Opened at
pSid
Opened at
_osid
nsid
Leaked
Did not Open C
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ tinsid
Repair
Tight ®
psid
Sid
RP sid
The above is certified to be true.
Firm Name &J t�Far- RoS
Firm Address L d9z III!7
( )a)C41LtczC.V1 to TjC
Gauge # Ofv 116015
Date last accuracy tested __.. q 5 2
Certified Tester JaS60 4(-),STco 0
Cert. Tester No. ao-X) G S 1 Date 46LL
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy