2013_1105 (4)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW P VENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: La Ae O
PWS I.D. #
LOCATION OF SERVICE: l o y 1 I iage.
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
o Reduced Pressure Principle
Double Check Valve
Manufacturer - (
Model Number om t I
Serial Number f' llS 30 I
TYPE OF ASSEMBLY
0 Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
.fit!
Size , _l
Located At 5et'U � e- 1T L l
The above is certified to be true.
Firm Name Qi7 e j Certified Tester f lel.,
Firm Address �% Cat Taster No. Date %
Gauge #��r
Date last accuracy tested ') 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 21
2nd Check
Initial Test
DC- Closed
Tight
RP -_psid
Closed Tight )C
Leaked o
Opened at
Psid
Opened at
_ nsid
,_,nsid
Leaked o
Did not Open a
Leaked a
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight a
_ ^nsid
nsid
RP sid
The above is certified to be true.
Firm Name Qi7 e j Certified Tester f lel.,
Firm Address �% Cat Taster No. Date %
Gauge #��r
Date last accuracy tested ') 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy