2014_0407 (8)CHECK ONE:
IRRIGATION DOMESTIC FIRELINEL_jo o
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L,,-T\/ e (--
PWS I.D. # PIJLI 4-e
LOCATION OF SERVICE: g U 0 N v: d �e-t A
The backllow prevention assembly detailed below has been tested and ►maintained as required by TCEQ
rcL,ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
P Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer LJC -,-15 Size 1-t
Model Number 00') 1" 2
Serial Number 16, `tp 6'
Located At 50 Lk. L. 1. -r-
The above is certified to be true. y r 5
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm
Address h) Pax `Xt 7 k),
Cert. Tester No. 006 q 4 a i-
Date ) IN
1st Check
tad Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,b
Opened at
Opened at
psid
v, \
Tight it
Leaked � ❑
psid
osid
RP- psid
Leafed 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 r 5
Firm
Name A C �,,, -A {= ^z
Certified Testa NkfAc, j^J
r K h "
Firm
Address h) Pax `Xt 7 k),
Cert. Tester No. 006 q 4 a i-
Date ) IN
Gauge # 0,2) G,jj a, f
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy