2014_0403 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE 3
BACKFLOW PREVENTION IASSEM 3LY TEST AND MAINTENANCE REPORT
NAME OF PWS: co Z- `
PWS I.D. #
LOCATION OF SERVICE: 06"
e
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
it Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number �" Located At
Serial Number 810 ,.19
The above is certified to be true.
Firm Name L� J-0�, C , s `� i,. " &-r + f/ erdfied Tester
Firm Address DcL c .vr r ►' 7 % Cut Testa No.
Gauge #
Date last accuracy tested l -I3 `%7
X-V` i'
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
Tight 1, `1 Rr
Closed Tight it
Leaked O
Opened at
nsid
Opened at
osid
paid
P6.575,
RP- __—psid
Leaked o
f ` /
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight C
p sid
osid
RP sid
The above is certified to be true.
Firm Name L� J-0�, C , s `� i,. " &-r + f/ erdfied Tester
Firm Address DcL c .vr r ►' 7 % Cut Testa No.
Gauge #
Date last accuracy tested l -I3 `%7
X-V` i'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy