2013_0905 (2)CHECK ONE:
IRRIGATION
DOMESTIC X
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: %n �l Uf01
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
re�oulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
X Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
rm /IS Size It
Model Number 7N11 Located At 4
Serial Number A
The above is certified to be true.
Firm Name �nn Fire Pra.
Firm Address I &x 1_97 11h)a W 1�
ix )-,5i (o5
Gauge # _0 01(0(x475
Date last accuracy tested 1 /,,5 113
• .I ,� .
Cent, Tester No. ` M I C 46 ! Date
White - Customer's Copy YeIIow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check: Z. o
2nd Check: Z-0
initial Test
DC- Closed
Closed Tight JFj
Opened at
Opened at
psid
Tight X,
Leaked
psid
psid
RP— ,_psid
Leaked C
Did not Open O
Leaked ❑
Repairs
and
Materials
Used
Test ARcr
DC- Closed
Closed Tight o
Opened at
Opened at
_; sid
Repair
Tight o
psid
osid
RP sid
The above is certified to be true.
Firm Name �nn Fire Pra.
Firm Address I &x 1_97 11h)a W 1�
ix )-,5i (o5
Gauge # _0 01(0(x475
Date last accuracy tested 1 /,,5 113
• .I ,� .
Cent, Tester No. ` M I C 46 ! Date
White - Customer's Copy YeIIow - City Copy Pink - Tester's Copy