2014_0407 (9)CHECK ONE:
IRRIGATION V" DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ? /.r LE
PWS I.D. #t�
LOCATION OF SERVICE: Hyy Qt J r,^ A
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
re ""nations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
a9 Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer LIE.. 7-1 S Size
Model ?number 00'7 M i Located At 4'��l i �c -t ' �r% Wt <--
Serial Number A d& 6 3 o
The above is certified to be true. V e 5
Firm Name -riv �
�n '- -
Firm Address PO &>4- "2c;i We ya
Gauge # 035; ci ; r3� / J
Date last accuracy tested -3//4
Certified Tester Wen" .r,-
Cert. Testa No. 60,)9-0 Date '0114
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
f PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight J6
Opened at
Opened at
_pSid
��
Tit f , 64
RP- _pSid
Leaked ❑
psid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true. V e 5
Firm Name -riv �
�n '- -
Firm Address PO &>4- "2c;i We ya
Gauge # 035; ci ; r3� / J
Date last accuracy tested -3//4
Certified Tester Wen" .r,-
Cert. Testa No. 60,)9-0 Date '0114
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy