2014_0407 (10)CHECK ONE:
IRRIGATION�� DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: q00
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
rcUulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
S3 Double Check Valve Atmosphere Vacuum Breaker
Manufacauer We r -r S Size a�
Model Number 00) wi I Located At 0!1 5 i ✓ec. fie, i yt c T L
Serial Number A a 6b, q0
The above is certified to be true. Y v- 5
Firm Name At Tic- v\
Firm Addre& P.o - �& R 7 ,)7 Uom
Gauge # -6)3c)6 --)j 18
Date last accuracy tested
Certified Tester
Cat Tester No. 0 c) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
]Check
1st Check:
2nd Check:
Relief Valve
:fir Inlet
Valve
Initial Test
h4
DC- Closed
Tight (, Cv
Closed Tight ib
Leaked & o
Opened at
psid
Opened at
psid
psid
RP- ___,psid
Leaked ❑
Did not Open D
Leaked
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight D
nsid
nsid
RP sid
1
11
The above is certified to be true. Y v- 5
Firm Name At Tic- v\
Firm Addre& P.o - �& R 7 ,)7 Uom
Gauge # -6)3c)6 --)j 18
Date last accuracy tested
Certified Tester
Cat Tester No. 0 c) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy