2014_0320 (2)CHECK ONE:
IRRIGATION Y DOMESTIC FIR.ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L r ?
PWS I.D. #
LOCATION OF SERVICE: `7ou w • 'f -tee
The backilow 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
�R' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Fe l"Cb Size eZ i
Model Number 860 Located At !2 () -� bq V,4,, f T'
Serial Numbers lv Z
The above is certified to be true.
Firm Name AC f t 011 L f k qQC, Certified T � i l ko <� )
L) .v.
Firm Address ` ,VX q 4 k o(�i O Cert. Testy No. ,k t Toni Date
/ ")51
Gauge # U011607-5
Date last accuracy tested Cf
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed 2.0
Closed Tight k
Opened at
Opened at
nsid
Tight ,6
Leaked � ❑
psid
nsid
RP- nsid
Leased ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name AC f t 011 L f k qQC, Certified T � i l ko <� )
L) .v.
Firm Address ` ,VX q 4 k o(�i O Cert. Testy No. ,k t Toni Date
/ ")51
Gauge # U011607-5
Date last accuracy tested Cf
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy