2014_0320 (3)CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE X
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 7o® w . 0, -i l•�e_. �
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.
a Reduced Pressure Principle
yA Double Check Valve
Manufacturer uje,, 4 s
Model Number 60
Serial Number AIb 11 aq
TYPE OF ASSEMBLY
o Pressure Vacuum Breaker
to Atmosphere Vacuum Breaker
Size 3% It
Located At r t y-e Lkq Lc
The above is certified to be true.
Firm Name i c? n l- l v'.9- - ( .R r s Certified Tester __ _ yr &S ro j
Firm Address 1� 1361k `lCi Luc-" 11 d c ki Lk Cent Tester No. �, j P4 , / _ Date 312oll
Gauge # t)�, /too 15
Date last accuracy tested —jb-/0—
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
Aar Inlet
Check Valve
Initial Test
DC- Closed j, W
Closed Tight
Opened at
Opened at
nsid
Tight
Leaked �, Z t3
gsid
nsid
RP- -_„rnsid
Leaked O
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
� sid
Repair
Tight O
Psid
psid
RP,,,,42sid
The above is certified to be true.
Firm Name i c? n l- l v'.9- - ( .R r s Certified Tester __ _ yr &S ro j
Firm Address 1� 1361k `lCi Luc-" 11 d c ki Lk Cent Tester No. �, j P4 , / _ Date 312oll
Gauge # t)�, /too 15
Date last accuracy tested —jb-/0—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy