2013_0905 (3)CHECK ONE:
IR..RIGATION
DOMESTIC K
FIRELINE
BACKFLOW PREVENTION .ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L 17 `l
PWS I.D. #
LOCATION OF SERVICE: 2qO AVi 2►'3d
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
re"Lllations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufac:�er flil,! �5 ��� size 211
Model Number 126`7191/ Located At (w% n LQ kl b,4
Serial Number ire 99 2
The above is certified to be true.
Firm Name �nn 1t,re- Pr n
Firm Address Pb &CX 7 9 7 ll w �°ile-S
.TX r) s105
Gauge # 0!5 I (&0 75
Certified Tester k1son
Date Last accuracy tested —Itl-54�
• &1! I 1 .
White - Customer's Copy Yellow - 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: 2.
2nd Check: 2.2
Initial Test
DC- Closed
Closed Tight )K
Opened at
Opened at
_---psid
Tight '3(
Leaked ❑
psid
psid
RP- _____psid
Leaked ❑
Did not Open ❑
Leaked D
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
tssid
RP sid
The above is certified to be true.
Firm Name �nn 1t,re- Pr n
Firm Address Pb &CX 7 9 7 ll w �°ile-S
.TX r) s105
Gauge # 0!5 I (&0 75
Certified Tester k1son
Date Last accuracy tested —Itl-54�
• &1! I 1 .
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy