2014_0410CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE�`
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L.. 17 `l C2 T 12- ar /1
PWS I.D. #
LOCATION OF SERVICE: 2410 Dividend
The backllow prey 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
g� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer (,(/it S_ Size
Model Number "7„-74 NIA, Located At �,.. r1a i mdh
Serial Number , 1 10021
The above is cce Ras
to be true
Firm Name &l nn Fire i'as
Firm Address 0 &X-79-7 (Q 5
Gauge # 0o / (C e 75
Date last accuracy tested 5
Cerdfied Tester Jrlspn
• r �� Dam
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEINOLY
PRESSURE VACUUM BREAKER
Double Check Valve Ass embly
Fay 1
.-
Ist Check: 0.0
2nd Check: 3.o
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tzaht G
Closed Tight )K
Leaked M
Opened at
psid
Opened at
_nsid
`nsid
RP- .psid
Leaked
Did not Open C1
Leaked ❑
Repairs
and
Materials
Used
Test After
ReRepairTight
DC- Closed
Closed Tight 0
Opened at
psid
Opened at
nsid
--P nsid
RP sid
The above is cce Ras
to be true
Firm Name &l nn Fire i'as
Firm Address 0 &X-79-7 (Q 5
Gauge # 0o / (C e 75
Date last accuracy tested 5
Cerdfied Tester Jrlspn
• r �� Dam
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy