2013_0809 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACEnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: I In i uPrs4l Qud er" x
PWS I.D. #
LOCATION OF SERVICE: 100 1 F. Sic% l4ke _ L'vADe11 TX 25D l5
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
4Y Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer L%neS Size �sf
Model Number dVOO 13 M 3 Located At Sep/' /2mr» 13
Serial Number 03 2,?�2
The above is certified to be true.
Firm Name Fee L fe Scf� -�v Omen-&.-
Firm Address i W, Euless Blvd. &I e•ss 7X
7kgo
Gauge # lac (1 D3 S l
Date last ace cy tested
Cert Tester No. AP jj-1 735 Date 9-q-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 e
Opened at
Opened at
,_ nsid
Tight ❑
RP- gsid
Leaked 1 • ❑
sid
_� sid
led
Leaked
Did not Open ❑
Leaked ❑
Repairs
and
kkeds ', l check
Wye rejue
weds 1* A check
V41UC repked
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight
p sid
_ nsid
_nsid
RP sid
The above is certified to be true.
Firm Name Fee L fe Scf� -�v Omen-&.-
Firm Address i W, Euless Blvd. &I e•ss 7X
7kgo
Gauge # lac (1 D3 S l
Date last ace cy tested
Cert Tester No. AP jj-1 735 Date 9-q-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy