2014_0320 (4)CHECK ONE:
IRRIGATION
DOMESTIC k'
FIRELINE
BACK LOW PREVENTION ASSEMBLY TEST AND MAIN ENNANCE REPORT
NAME OF PWS: �f? L L�' t'r_n0,-tt
PWS I.D. 9
LOCATION OF SERVICE: ` x'00 W,
11w backllo« pre\ ention 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
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer aka / �-S` Size .- )I
Model dumber iW:7,61 t Located At iN 0 Y 6,T "la u f'
Serial Number I � I q y
The above is certified to be true.
Firm Name' ii n n b m tics Certified Tester (MO n fUSTO �
Firm Address k &x it kW -t %Ili ch r e. Cert. Tester No. Date
Gauge
Date last accuracy tested j
White - Customers 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 l d 3
Tilt 1<
Closed Tight te,
Leaked j. �; ❑
Opened at
psid
Opened at
�nSid
psid
RP- _,_.psid
Leaked e
Did not Open ❑
Leaked ❑
Repairs
and
iMaterials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
�.,osid
sid
RP sid - I
I
J
J
The above is certified to be true.
Firm Name' ii n n b m tics Certified Tester (MO n fUSTO �
Firm Address k &x it kW -t %Ili ch r e. Cert. Tester No. Date
Gauge
Date last accuracy tested j
White - Customers Copy Yellow - City Copy Pink - Tester's Copy