2013_0809 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE_ X
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: I In 1,jerS41 ric-n em I/
PWS I.D. #
LOCATION OF SERVICE: ImI E. Scnrl'v Lckp_; (-Iae /lI TX 2SnI2
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
q,-' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Ones Size 10 !t
Model Number 366-a - 16 T" Located At I < i S er goom
Serial Number A - mm
The above is certified to be true.
Firm Name FM L, Pe &f 0.eri Certified Tester L LA T "r,
Firm Address ,*spa i W. EJes mi f4hoss Tx AftCert Tester No. APMY17g5 Date 9-1-13
Gauge # 0 11 o3 ,!
Date last acccy tested
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
n sid
Tight
RP- 1, U sid
Leaked 3,3 ❑
nsid
nsid
ASS
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_----.p sid
Repair
Tight ❑
nsid
_,nsid
RP psid
The above is certified to be true.
Firm Name FM L, Pe &f 0.eri Certified Tester L LA T "r,
Firm Address ,*spa i W. EJes mi f4hoss Tx AftCert Tester No. APMY17g5 Date 9-1-13
Gauge # 0 11 o3 ,!
Date last acccy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy