2013_0809CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: S4 �lcad�►.., y
PWS I.D. #
LOCATION OF SERVICE: 100 t E.: ,L "Za ie , Qaaell TX ?SDI � if
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 ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
t" Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 0mes Size yIN
Model Number 1!' o ll 3M BF Located At R, se/' )QM07 A
Serial Number Fl- w o ? _
The above is certified to be true.
Firm Name Ea L . LeSa-fe ly L.[. & I' a
Firm Address A-21 Id-
F,, I ess TV 710#0
Gauge # %ZI1 d3KI
Date last acccy tested 3 ' 13
Certified Tester .�n /A-&;ms
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight e
Opened at
Opened at
nsid
Tight
sid
Leaked ❑
nsid
----__nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
_psid
_osid
RP sid
The above is certified to be true.
Firm Name Ea L . LeSa-fe ly L.[. & I' a
Firm Address A-21 Id-
F,, I ess TV 710#0
Gauge # %ZI1 d3KI
Date last acccy tested 3 ' 13
Certified Tester .�n /A-&;ms
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy