2013_0621 (8)CHECK ONE:
IRRIGATION
___ ,t _ DOMESTIC FIREUNE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
N.kME OF Pth'S:
PA'S 1. D. TM
LOCATION OF SERVICE: /� // 5.
T1,� hackllwv hrtn entkm assemhlN detailed below has bean tfcslcd ;wd mairltaiMed as required by TCEQ
rc_ >ul��!i�rti �Ifld is - milled try he operatillL, v 101111 acctptahic j are ineters.
TYPE OF ASSEMBLY
Reduced Pressure Princinie Pressure Vacuum Breaker
V Double Check Valve z Atmosphere Vacuum Breaker
Manufacture: r-c b. to Size
I-)�
Model Number (9 `i o Located At 5e,4 e, 9-0.4 J&,k; Njg PU .-,, %I 'P C15 M
Se: iai Number i l Q 1 11r'1
The above is certified to be true. I-e S
Firm Name /k I -eL) ,J C : -c-
Firm Address f U ad e '719 7
X'cv14CN,G
Certified Testa � �C•v v► � Lam' t , m vi el
Cent. Tester No. i2an ci,4 / cl i l- Date 61C)I & 3
Gauge # Q) 3j!j9djjj9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
i
j Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initiai Test
DC- Closed
Closed Tight 29
Opened at
Opened at
osid
Tight f,� j �
R.p- !_,psid
Leaked /,� ❑
_ nsid
osid
Leaked ❑
Did not Open O
Leaked ❑
Repairs
and
Materials
Used
f
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true. I-e S
Firm Name /k I -eL) ,J C : -c-
Firm Address f U ad e '719 7
X'cv14CN,G
Certified Testa � �C•v v► � Lam' t , m vi el
Cent. Tester No. i2an ci,4 / cl i l- Date 61C)I & 3
Gauge # Q) 3j!j9djjj9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy