2014_0403 (5)CHECK ONE:
IRRIGATION_ DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C-2
PWS I.D. #
LOCATION OF SERVICE: tir 1 c� - 201"e -ie C1�f. I Z12 jr. ,
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
4e Double Check Valve ❑ Atmosphere Vacuum Breaker
N
Manufacturer i- ��" Sir
Model Number A Located At /44 t ~ 4 iJ`�� • T`u' � Vc, r`G��
Serial Number 14 LIZ -5 &2
The above is certified to be true.
Firm Name C 1'
Firm Address y. ` f . �i ' 7.5
Gauge #
Date last accuracy tested l /3'
Certified Tester b V r
Cert. Testa No. ; 'I & Date q-3-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Cl o�s
Closed Tight V
Opened at
Opened at
nsid
Ti
Leaked ❑
RP -_psid
Leaked ❑
�osid
_nsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
_nsid
psid
RP sid
The above is certified to be true.
Firm Name C 1'
Firm Address y. ` f . �i ' 7.5
Gauge #
Date last accuracy tested l /3'
Certified Tester b V r
Cert. Testa No. ; 'I & Date q-3-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy