2014_0417 (2)CHECK ONE:
IRRIGATION
DOMESTIC IX FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: of
PWS I.D. #
LOCATION OF SERVICE:
I LJ %Lf. s t- lM L w�
The backtlow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
❑
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
DI ofu�ble Check Valve
Manufacturer
W l
Model Number
1st Check
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
kit tc
Located At C-XDV- A4� -W- t" *,r
The above is certified to be true.
Firm Name A l I RSA
4548 Pa>r:;n0AA.?- VLOw
Firm Address UT:744
Gauge # C)U t i 0Q(.Qq
Date last accuracy tested
Certified Testa `-�" r 5�� r sa-c✓�4+
Cat. Testa No. FpD0 I3 q_" Date r t —1 — I Lf
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
osid
Tight lid
RP -a • psid
Leaked ❑
Leaked ❑
1 '
psid
oSid
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 certified to be true.
Firm Name A l I RSA
4548 Pa>r:;n0AA.?- VLOw
Firm Address UT:744
Gauge # C)U t i 0Q(.Qq
Date last accuracy tested
Certified Testa `-�" r 5�� r sa-c✓�4+
Cat. Testa No. FpD0 I3 q_" Date r t —1 — I Lf
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy