2013_0708 (6)CHECK ONE:
IRRIGATION X DOMESTIC FIR.ELINE
BACI%TLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9 _XAS h
LOCATION OF SERVICE: 14. &)o
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 ASMEMBLY
Reduced Pressure Principle n Pressure Vacnmi Breaker
Double Check Valve c Atmosphere Vacuum Breaker
Manufac=er Febca Size fW #
Mode: Number 865/ Located At S)Lil-k (/04
Serial Number M- Z5'Z 2
The above is certified to be true.
Firm Name t-t e rl � ( R f 04
Firm Address PC) & -117
IrU0,x4Vi c, VA t e' --Tx
Gauge # C)& 116 l5
Date last accuracy tested 12
Certified Tester 4✓ aTC� r..l
Cent Tester No. �,P-Wlt6 S) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEINLBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed 1, `7i
Tilt
Closed Tight
Leaked
Opened at
psid
Opened at
asid
asid
RP— .._.,psid
' J
Leased o
Did not Open c
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight ❑
asid
psid
RP sid
The above is certified to be true.
Firm Name t-t e rl � ( R f 04
Firm Address PC) & -117
IrU0,x4Vi c, VA t e' --Tx
Gauge # C)& 116 l5
Date last accuracy tested 12
Certified Tester 4✓ aTC� r..l
Cent Tester No. �,P-Wlt6 S) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy