2013_1203CHECK ONE:
IRRIGATION DOMESTIC FIR.ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L I -T l c�e�0 12Ct1
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
a Reduced Pressure Principle ❑ Pressure Vacuum Breaker
)Z- Double Check Valve o Attnosphere Vacuum Breaker if
Manufacturer (��-ts Size )
Model Number � Located At AAk) r 1 Y� J AUU 17—
11040., a• r
The above is certified to be true.
Firm Name on rirz- Was
Firm Address Pd 66)6 79 %
xCc FaCk CL
TX-
Gauge # _0 G l I Cp7�
Date last accuracy tested ��� 13
CertifiedTcsta k SBA 9 S'ro iJ
Cat TesterNo. ta- Q63/ Bate f Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC-Closed,. 0
Tight
Closed Tight
Leaked
Opened at
psid
Opened at
psid
nsid
RP- „_„_psi
Leaked o
2
Did not Open C
Leaked
Repairs
and
Materials
Used
Test Ages
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
msid
Opened at
nsid
^_ ,rpsid
RP sid
The above is certified to be true.
Firm Name on rirz- Was
Firm Address Pd 66)6 79 %
xCc FaCk CL
TX-
Gauge # _0 G l I Cp7�
Date last accuracy tested ��� 13
CertifiedTcsta k SBA 9 S'ro iJ
Cat TesterNo. ta- Q63/ Bate f Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy