2014_0321 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE. �JM t(2 az-l"I
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
Q Reduced Pressure Principle
Double Check Valve
Manufacturer Ga74 fS
Model Number -7 7�
Seriai Number log-7 1%
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At Id &Lk %
The above is certified to be true.
Firm Name Ac (.e- Ls Certified Testa f /It &K Ls-Torj
Firm Address 11 Au '7q7 I. gXC&(Z h�CerL Te= No. ( Date
Ty
Gauge # 061112025 , • _-
Date last accuracy tested � 5
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 .3.2-
Closed Tight ;K
Opened at
Opened at
psid
Tight ❑
Leaked -3, G ❑
psid
psid
It - ,.__,.,psid
Leafed ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight ❑
psid
ttsid
RP sid
The above is certified to be true.
Firm Name Ac (.e- Ls Certified Testa f /It &K Ls-Torj
Firm Address 11 Au '7q7 I. gXC&(Z h�CerL Te= No. ( Date
Ty
Gauge # 061112025 , • _-
Date last accuracy tested � 5
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy