2013_0809 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Un 10Ar Sa I OccidPfi u
PWS I.D. #
LOCATION OF SERVICE: 1001 E. Snag& 14 . CWO&// T,Y 25019
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
&I" Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ( rneS Size G to
Model Number 306a • 13r-'
Serial Number , 7P- 030fr
Located At R 1 se'r %icom C
The above is certified to be true.
Firm Name Fig L A &fe j u Omerle
Firm Address AA i 6g.EJ#a PJJ- L. s —N
7,040
Gauge # 01103 51
Date last acettey tested
Cert. Tester No. 5 Date
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 e
Leaked 3. % ❑
psid
nsid
RP--L. Y sid
_
GSS
Leaked C3
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
� sid
Repair
Tight
p sid
_ nsid
RP sid
The above is certified to be true.
Firm Name Fig L A &fe j u Omerle
Firm Address AA i 6g.EJ#a PJJ- L. s —N
7,040
Gauge # 01103 51
Date last acettey tested
Cert. Tester No. 5 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy