2013_0905CHECK ONE:
IRRIGATION DOMES'T'IC FIRELINE X
BAC10rLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 2 '40 D l v id eAd
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
s Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer a ja4s Size 21J 7
Model Number 661A 57- Located At rjn2 Vau
Serial Number /6 /2 q
The above is certifies to be true.
Firm Name kimn f;r4 Rrn s Certified Testa loo Lll�
Firm Address pb (*%9 ,i Ui Wt I e6 Cut Testa No. '?)PCY)1C o5 f Date
TX '"1511Q5
Gauge # __a 1 f L2 5
Date last accuracy tested —454�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
n
QS
1st Check
Znd Check O
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight )K
Closed Tight
Leaked
Opened at
pSid
Opened at
�nsid
pSid
RP- ..psid
E
Leaked
Did not Open C
Leaked
Repairs
and j
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nSid
Repair
Tight C
-� sid
Sid
RP sid
The above is certifies to be true.
Firm Name kimn f;r4 Rrn s Certified Testa loo Lll�
Firm Address pb (*%9 ,i Ui Wt I e6 Cut Testa No. '?)PCY)1C o5 f Date
TX '"1511Q5
Gauge # __a 1 f L2 5
Date last accuracy tested —454�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy