2014_0321 (2)CHECK ONE:
IRRIGATION
DOMESTIC A
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L. 17 -,Lc 12- i2e,zI
PWS I.D. 9
LOCATION OF SERVICE: W et)kl"-
The backllow prev,entwn assembly detailed below has been tasted and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle M Pressure Vacuum Breaker
,X Double Check Valve Atmosphere Vacuum Breaker
Manufacturer Lao Ls Size 2;f
Model Number D07114 Located At c w 4-�e- r
Serial Number In Z1
The above is certified to be true.
Firm Name F `}stn fA Ye RCS Certified Tester JtScrt t6TW
Firm Address — ZX Zi 7 Ith&f (rtW hte Cert. Tester No. ( L. Date 3 &
Gauge #-O-A(2(2 7 5
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
Relief Valve
Air Inlet
Check Valve
1st Check:
2nd Check:
Initial Test
DC- Closed 2 L-'
Tight
Closed Tight
Leaked G
Opened at
psid
Opened at
osid
RP --_--- -psid
,osid
Leaked O
Did not Open o
Leaked G
Repair
and
Materials
Used
Test Af rz
Repair
DC- Closed
Tight Q
Closed Tight Cl
Opened at
-_ _psid
Opened at
_-...- psid
�nsid
RP rid
The above is certified to be true.
Firm Name F `}stn fA Ye RCS Certified Tester JtScrt t6TW
Firm Address — ZX Zi 7 Ith&f (rtW hte Cert. Tester No. ( L. Date 3 &
Gauge #-O-A(2(2 7 5
Date last accuracy tested
White - Customer's Copy Yellow - City Copy .Pink - Tester's Copy