2014_0407 (5)CHECK ONE:
IRRIGATION $0 DOMESTIC
FIRELINE
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ( I'7' e - 0
PWS I.D. # t��o L r t
LOCATION OF SERVICE: j VC) IN v'
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
re111.11ations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
t, Reduced Pressure Principle C Pressure Vacuum Breaker
SP Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Iii= - 3 Size 1)
Model Number 00') wt 1 Located At I-x 51 A a � ►fit e �
Serial Number A c) G
The above is certified to be true. y-e i
Firm Name 4e tin C,,-
Firm Address Po 0,1 (,, '-) "I .-) 0 c,,-
Gauge # 0- 11: Ji D,
Date last accuracy tested 31ill
' Certified Tester WflY c W e u —
Cent Tester No. Date 4-t ! 7 l r1t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEM3LY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
h'1
DC- Closed
Tight , U Z
RP- psid
Closed Tight la
Leaked ❑
Opened at
psid
Opened at
oSid
osid
Leaked O
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight O
psid
oSid
RP Sid
The above is certified to be true. y-e i
Firm Name 4e tin C,,-
Firm Address Po 0,1 (,, '-) "I .-) 0 c,,-
Gauge # 0- 11: Ji D,
Date last accuracy tested 31ill
' Certified Tester WflY c W e u —
Cent Tester No. Date 4-t ! 7 l r1t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy