2014_0403 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:r
PWS I.D. #
LOCATION OF SERVICE: -5EL' u.; °1,1 d-4- C'{Wj I-V
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.
J9
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
site
3111
Located At
`ofi�aa
The above is certified to be true.
Firm Name d,Certified Tester
Firm Address Qi-(,,L ti.VA " 7`le" i3? Cert. Tester No.
Gauge # / Oaf / J I/
Date last accuracy tested _, 1-13
P-270 1 Date
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- Closed
Closed Tight W
Opened at
Opened at
nsid
rC365r
Tight l•(0 tt
RP -----psid
Leaked ❑
/: a
nsid
_nsid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight ❑
nsid
I
nsid
L
RP sid-
The above is certified to be true.
Firm Name d,Certified Tester
Firm Address Qi-(,,L ti.VA " 7`le" i3? Cert. Tester No.
Gauge # / Oaf / J I/
Date last accuracy tested _, 1-13
P-270 1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy