2013_0809 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE ✓
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 016 fiver Sa,l Q C4rokm y
PWS I.D. #
LOCATION OF SERVICE: 100/ 9, C044ell 7y 7-ol q
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
91" Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 6ineS Size Yy
Model Number 40M A /h 3 Located At A -snr Room A
Serial Number 03 7q8'
The above is certified to be true.
Firm Name ryto Ll �e -cn „ Ornernca
Firm Address aFiat 1d.E.1esS Bled_ rJ-1- x
F.
700
Gauge # 1,211 b l 5 I
Date last acccy tested 3 ' .S' 1 3
" -q, ' /"
Cut Tester No. 130=015 Date 9j-13
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
Opened at
Opened at
p sid
$S
Tight
RP- Lo-2--osid
Leaked ❑
Leaked ❑
(4
_nsid
_esid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
� sid
Repair
Tight ❑
_psid
_psid
RP sid
ii
The above is certified to be true.
Firm Name ryto Ll �e -cn „ Ornernca
Firm Address aFiat 1d.E.1esS Bled_ rJ-1- x
F.
700
Gauge # 1,211 b l 5 I
Date last acccy tested 3 ' .S' 1 3
" -q, ' /"
Cut Tester No. 130=015 Date 9j-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy