2014_0407 (7)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE WIC, H try we
BACEFLOW PREVENTION ASSEMBLY TEST AND MAP4TENANCE REPORT
NAME OFPWS: L/7 el
PWS I.D. # () r- r-
LOCATION OF SERVICE: '-1&j to i r�
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
reUulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vacuum. Breaker
W Double Check Valve &, 014 C Atmosphere Vacuum Breaker
Manufacturer k�-- -r- -T S Size
Model Number 77,i, I OG flh Located At w yc v
Serial Number 10 G1 dJP
The above is certified to be true. y -,-- 7
Firm Name A e moo r ; Certified Testa c. W �, V% •-
Firm Address PV &x '79'-7 W(I )c Cat. Testa No. Q M &/J Date Al f `�
Gauge # 12��
Date last accuracy tested ] r�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSE:ISLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Chem►.
2nd Check
Initial Test
\`)
DC- Closed
Tight : 4 P
RP -�psid
Closed Tight ;fi
Leaked d
Opened at
sid
Opened at
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Retiairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
nsid
nsid
RP sid
The above is certified to be true. y -,-- 7
Firm Name A e moo r ; Certified Testa c. W �, V% •-
Firm Address PV &x '79'-7 W(I )c Cat. Testa No. Q M &/J Date Al f `�
Gauge # 12��
Date last accuracy tested ] r�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy