2014_0417 (5)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
v'
PWS I.D. #
LOCATION OF SERVICE: @U(6(,-Tn,P * q t u
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
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size I)-
Located At
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
D'' oAAubleyCheck Valve
Manufacturer
Vv111�5
Model Number
Serial Number
O y A l U
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size I)-
Located At
The above is certified to be true.
Firm Name u IL2 Certified Tester Ch � �i � - b �"w
Firm Address I U 1'� Cert. Tester No.�fl.�Date " �4
Gauge # OU I (o t
Date last accuracy tested
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 AC
Opened at
Opened at
psid
C
J
Ti
RP�D psid
Leaked ❑
g Leaked ❑
psid
l
psid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name u IL2 Certified Tester Ch � �i � - b �"w
Firm Address I U 1'� Cert. Tester No.�fl.�Date " �4
Gauge # OU I (o t
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy