2014_0417CHECK ONE: /
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ur-\-T,
PWS I.D. #
LOCATION OF SERVICE:
S -E;W lam" 1�
The backtlow prevention ass Inbly etailed 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
Double Check Valve C Atmos {phere Vacuum Breaker
Manufacturer
UUl I ly. VAS size 1 ,/2 tt
Model Number Located At 75E--- GOrI(1,Q ' i NAA P
Serial Number K& -c,
The above is jcertified to be true.
Firm Name
Firm Address g WS t1ftWtV I�W
htit l( , 7 1-1114 {
Gauge # W IL (O U
Date last accuracy tested � - V - l
Certified Testae
Cat. Testa No. t'� Date 14
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 'i
Opened at
Opened at
pSid
Tights
RP -,:; !"psid
Leaked ❑
Leaked ❑
�''
psid
pSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
pSid
Repair
Tight ❑
psid
pSid
RP sid
The above is jcertified to be true.
Firm Name
Firm Address g WS t1ftWtV I�W
htit l( , 7 1-1114 {
Gauge # W IL (O U
Date last accuracy tested � - V - l
Certified Testae
Cat. Testa No. t'� Date 14
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy