2014_0407 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X & . PG 3S
BAMLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: (� L F Lc 17�r�f
PWS I.D. U rr-
LOCATION OF SERVICE: v1w b%V i ate.^ 6
The backllovv prevention assembly detailed below has been tested and maintained as required by TCEQ
rcuulatioils and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ri Pressure Vacuum Breaker
V Double Check Valve n Atmosphere Vacuum Breaker
Manufacturer Wr- -r-r i Size 314
Model Number 00'7M ) Located At TVN Ur.%y
Serial Number 1 -15- /, &
The above is certified to be true. Y-e
Firm Name Al rtu,,+ (-:
Firm Address Po Nv k ?'7'7
Gauge # 0 3 o f :7 !
Date last accuracy tested 3111,
Certified Tcster td r vv ^ -
Cent. Tester No. i.A:X of "1J Date "1 0 11'1
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
Ist Check
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
asid
h�
Tight 1. &
RP_ pSid
Leaked ❑
psid
aSid
Leaked ❑
Did not Open o
Leaked ❑
Rcaairs
and
Materials
Used
Test After
DC- Closed
Closed Tight t?
Opened at
Opened at
pSid
Repair
Tight o
psid
pSid
RP sid
The above is certified to be true. Y-e
Firm Name Al rtu,,+ (-:
Firm Address Po Nv k ?'7'7
Gauge # 0 3 o f :7 !
Date last accuracy tested 3111,
Certified Tcster td r vv ^ -
Cent. Tester No. i.A:X of "1J Date "1 0 11'1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy