2014_0407 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ( r "? ,1 e (1 't _
PWS I.D. 9 5-u K-Iff
LOCATION OF SERVICE: q00 bidicleqco
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
reUlulations and is certified to be operating -within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer We T ? 5 Size
Model Number 00 7 M i Located At nVA
Serial Number A d& G 3 7
The above is certified to be true. ye 5
Firm Name Certified Tester Njq� I e- L,d k- -V n z1
Firm Address QJ dax 7 17 O, a )c Cert. Testa No. 0 00 or 10 Date <A=7 7 %/�
Gauge # 0 3d> °r,9_d f
Date last accuracy tested 3/1-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEl1IBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
Q 0j 13
DC- Closed
Tit 1, `J &P
RP- ---.psid
Closed Tight V
Leaked � ❑
Opened at
psid
Opened at
_� sid
osid
Leaked
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test Afia
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
oSid
osid
RP sid
The above is certified to be true. ye 5
Firm Name Certified Tester Njq� I e- L,d k- -V n z1
Firm Address QJ dax 7 17 O, a )c Cert. Testa No. 0 00 or 10 Date <A=7 7 %/�
Gauge # 0 3d> °r,9_d f
Date last accuracy tested 3/1-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy