2014_0407 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L, T 1-2
PWS I.D. # t) K-
LOCATION OF SERVICE: N0t3 Nw, ,
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
red 'lulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
G Reduced Pressure Principle ^ Pressure Vacuum Breaker
NC� Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Wo T -, 5 Sue d
Model Number CYi0wl ( Located At AR60nn 0C IS-3,z4,-3
bl- v
Serial Number 7
The above is certified to be true. Y— 5
Firm Name Ac (='• ^e
Film Address Pei G." n -7 V1,7 �G �
Gauge # >3c ,)6 9.918
Date last accuracy tested 3/14
Certified Tester We-^ v�-"
Cent. Tester No. 00074? 1- Date -1 /,) f 1 N
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSET IBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 16
Opened at
Opened at
nSid
�tO
�
Ti t 1: fd 116
RP- _____nsid
Leaked C3
nsid
Sid
Leaked ❑
Did not Open o
Leaked o
Reaairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true. Y— 5
Firm Name Ac (='• ^e
Film Address Pei G." n -7 V1,7 �G �
Gauge # >3c ,)6 9.918
Date last accuracy tested 3/14
Certified Tester We-^ v�-"
Cent. Tester No. 00074? 1- Date -1 /,) f 1 N
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy