2014_0407 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE� >.h
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L f 1
PWS I.D. it t) t z
LOCATION OF SERVICE: NUtI �ty ►�.r�d
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
re�u,ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacui n Breaker
R Double Check Valve pf, !14 ❑ Atmosphere Vacuum Breaker
Manufacturer Or, T-i S Size i
Model Number -7"711 ;,�G () Located At yo tTh O c,- sir
Serial Number l oo,71311 o )
The above is certified to be true. Y,- 3
Firm Name A i rlw•i
Fins Address Qd (K., R 7 1 1 in•'---,a
Gauge # p 3(-, f; _� ia_
Date last accuracy tested V/4—
Certified Tester N Wj -i -4- Lle 4A �e-
Cert. Tester No. 1900'1"1 ) J— Date `l ► r I'i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEINIBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight V
Opened at
Opened at
nsid
Gyp
,j
Ti 6t c9.0 �
RP- _,psid
Leaked ),07 ❑
psid
nsid
Leaked C
Did not Open ❑
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
_ psid
osid
RP sid
The above is certified to be true. Y,- 3
Firm Name A i rlw•i
Fins Address Qd (K., R 7 1 1 in•'---,a
Gauge # p 3(-, f; _� ia_
Date last accuracy tested V/4—
Certified Tester N Wj -i -4- Lle 4A �e-
Cert. Tester No. 1900'1"1 ) J— Date `l ► r I'i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy