2014_0417 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: I
PWS I.D. #
LOCATION OF SERVICE: @ULL Tr, P -0 t'` �
14q S. bd f- Wu Imo.
The backflow prevention ssembly 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
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer W L Size Manufacturer it
Model Number 00 L1 y `? Located At S�p c,,y— V-00 Al
Serial Number ?A0 o
The above is (cer filed to be true.
Firm Name
Firm Address Llcm Wn!2�± V1 co
" PAY; qi - jl. )A
Gauge # 1 0000 6) G
Date last accuracy tested
Certified Testa NoslypV1-e r 5AWL -
Car Testa No. -3 4 1 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
SS
DC- Closed
Ti
RP� psid
Closed Tight
Lcal:ed ❑
'n
Opened- at
0 psid
Opened at
-id
osid
Leaked ❑
W
Dud not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
oSid
RP sid
The above is (cer filed to be true.
Firm Name
Firm Address Llcm Wn!2�± V1 co
" PAY; qi - jl. )A
Gauge # 1 0000 6) G
Date last accuracy tested
Certified Testa NoslypV1-e r 5AWL -
Car Testa No. -3 4 1 Date 14
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy