2014_0407CHEC K ONE:
IRRIGATION_ __# DOMESTIC
FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: _ _ L / I 'l G' C r n 1
PWS I.D. 4! k�
LOCATION OF SERVICE: Llvc.:)
The backflow prey °ention assembly detailed below has been tested and maintained as required by TCEQ `
re-ulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
9► Double Check Valve
Manufacturer UJ,----o
Model Number 001 M I
Serial Number A cP t 6-0 6,
TYPE OF ASSEMBLY
❑ Pressure Vacuum. Breaker
C Atmosphere Vacuum Breaker
Size
Located At On 5 ir=- rj�&_ IMr rr-
The above is certified to be true. y - 5
Firm Name AC "T'tr, -,1 (7. Certified Tester Nt k,4 u- W � .� •� �
Firm Address PO (&-, N 7 J 7 Cat Taster No. _C)cv) r -0 Date &I
Gauge ## t �,
Date last accuracy tested _ 3 j/N
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
2nd Check
Initial Test
DC- Closed
Closed Tight ❑
Opened at Opened at
asid
Tight �:�.d ►
Leaked p6-
psid psid
- --`
1L
RP -_psid
Leaked ❑�
Did not Open ❑
Lraled ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at Opened at
psid
Repair
Tight C
psid psid
RP sid
The above is certified to be true. y - 5
Firm Name AC "T'tr, -,1 (7. Certified Tester Nt k,4 u- W � .� •� �
Firm Address PO (&-, N 7 J 7 Cat Taster No. _C)cv) r -0 Date &I
Gauge ## t �,
Date last accuracy tested _ 3 j/N
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy