2014_0320CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE >".
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: �1? f �� �c•(}p�,f�
PWS I.D. #
LOCATION OF SERVICE: __700 ,w
The backilo w prerentl na 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
0 Reduced Pressure Principle C Pressure Vacuum Breaker
0 Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer Wa44 `� Size
Model Number 7 ? `f Located At Fi y "� Its I
Serial Number
The above is certified to be true.
Firm Name A boys LIts y- .LS Catified Tester Vi Py S i,,J
Firm Address C� a x 7y 7 fA 1 a ot� c Vk jk Cert. Tester No. Date
rte-
Gauge # 14—
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
Opened at
Opened at
psid
'Tilt
Leaked -Z. 6 D
psid
osid
RP- ,,,,psid
Leaked C
Did not Open D
Leaked a
Repair
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
w�sid
Repair
Tight D
_ _ psid
psid
RP sid
The above is certified to be true.
Firm Name A boys LIts y- .LS Catified Tester Vi Py S i,,J
Firm Address C� a x 7y 7 fA 1 a ot� c Vk jk Cert. Tester No. Date
rte-
Gauge # 14—
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy