2013_0809 (6)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE_V--'
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 1jrn iuel'541 1�)cadegh u
PWS I.D. #
LOCATION OF SERVICE: 6m cell TX ? So /g
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
5,' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Oftl eS Size 11V
Model Number dWO A M 3
Serial Number ba QI
• -•
The above is certified to be true.
Firm Name Fire LX- Rarij„ C ,"&L
Firm Address_ ales i W_ Ejass ad. E'ul Pss TV
.
?&MO
Gauge # - 2110351
Date last acecy tested-3-5-13
Certified Tester do Ts
Cert. Tester No. APco/ll AS Date ?-F-/.3
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
_nsid
Tight ❑
Leaked 0. o ❑
sid
nsid
RP- ,Q.Q -,psid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Peeols
V41U &, beec-uSe of
is Cracked
it I l
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-----p sid
Repair
Tight ❑
osid
�nsid
LlUsed
RP sid
The above is certified to be true.
Firm Name Fire LX- Rarij„ C ,"&L
Firm Address_ ales i W_ Ejass ad. E'ul Pss TV
.
?&MO
Gauge # - 2110351
Date last acecy tested-3-5-13
Certified Tester do Ts
Cert. Tester No. APco/ll AS Date ?-F-/.3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy