2014_0403 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: �:� /1 n ff
PWS I.D. #
LOCATION OF SERVICE:
, -c t"r jaz-k 5fo iy,,je C��r, 3 Z0 5
.�rIIct
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
sr Double Check Valve 1?e fe-'y ❑ Atmosphere Vacuum Breaker
Manufacturer 1-4? bco Size
Model Number`` Located At s �'
Serial Number
The above is certified to be true.
Firm Namei � ' � �' ��' �
Firm Address b.--t c,0,dY',I fe-1 i "13
Gauge #
Date last accuracy tested/ 3, l
Certified Tester 00 for
Cert. Tester No. iG'yDate -r �3 %7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight O'
Opened at
Opened at
osid
Tight X
Leaked ❑
nsid
_osid
PC15-j
RP- __paid
Leaked C3
`-
�'
Did not Open C3
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_-psi d
Repair
Tight C3
psid
osid
RP sid
The above is certified to be true.
Firm Namei � ' � �' ��' �
Firm Address b.--t c,0,dY',I fe-1 i "13
Gauge #
Date last accuracy tested/ 3, l
Certified Tester 00 for
Cert. Tester No. iG'yDate -r �3 %7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy