2014_0417 (4)CHECK ONE:
IRRIGATION
DOMESTIC V FIRELINE
BA=OW PREVENTION (A'SSSEM 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. # _ /�
LOCATION OF SERVICE:�l ��u v I
Aq S. o 1t- . VA
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double �Check Valve ❑ Atmosphere Vacuum Breaker
W
Manufacturer —000w\ l % _ Size .314 ((
Model Number ) Located At 1,3tocy-' "M
serial Number *- u 0 q �) b
The above is certified to be true.
Firm Name I ' 1 ( T-
Firm Addnxs q5`1� I v IU U IV l3Vt,��
Gauge # I a)(A
Date last accuracy tested-2-S-3
Certified Tester
Cat. Tester No.EOO INRI Date L'L —! 7 - f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
S
1st Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tigh X
RP -psid
Leaked ❑
Leaked ❑
psid
a- 0
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name I ' 1 ( T-
Firm Addnxs q5`1� I v IU U IV l3Vt,��
Gauge # I a)(A
Date last accuracy tested-2-S-3
Certified Tester
Cat. Tester No.EOO INRI Date L'L —! 7 - f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy