2014_0321 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS:
PWS I.D. 9
LOCATION OF SERVICE: &n (,c _ ZV �W.
The backllow pre%;entfon assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure PrmciDle
Double Check Valve
Manufacturer f.( a � 15
Model Number OL MZ
Serial Number /3 J 7 %
TYPE OF ASSEMBLY
Pressure Vaantm Breaker
e Atmosphere Vacuum Breaker
size 3& "
Located At aU
f
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
I Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight X
Leaked 2 ,0 C
Opened at
psid
Opened at
,usid
usid
RP- -w„_„psid
Leaked C
Did not Open o
Leaked c
Repairs
i
and i
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
sid
Repair
Tight
psid
usid
RP sid
T he above is certified to be true.
Firm Name 4C 1nio Gr Q- Kl2b-S� Certified Tester 1 f"n o a,) c.M C j
Firm Address JI&V lam a b lyf b-1i (4 pert Tester No. 5Phn j()6,`; f Date 3/2j
Gauge # - (L4-
Bate last accuracy tested .5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy