2013_0621 (9)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE KI
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ? `/ e� (- L/c' lit /I
PWS I.D. 9
LOCATION OF SERVICE: '
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 a Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 4j P /, S h Size
Model Number 4,6 A) G
Serial Number 9 Cj / 38 3
/w
Located At (,J 04 P CIV C L
The above is certified to be true. 'I-e, 5
Firm Name PO T -m) ,/ C q t
Firm Address 66 X; �7 C2
Gauge #
Date last accuracy tested 3/
Certified Tester Lida, e W e in V) t-41,
Cert. Tester No. ��n qE / r) s^ Date 6 1C)I &
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight AD
Opened at
Opened at
nsid
Tight V
RP- ^L)sid
Leaked % ❑
psid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
CIosed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
i asid
nsid
RP sit
The above is certified to be true. 'I-e, 5
Firm Name PO T -m) ,/ C q t
Firm Address 66 X; �7 C2
Gauge #
Date last accuracy tested 3/
Certified Tester Lida, e W e in V) t-41,
Cert. Tester No. ��n qE / r) s^ Date 6 1C)I &
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy