2014_0403CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE I," _
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
C!
PWS I.D. #
LOCATION OF SERVICE: 'Saz w' i0ck 64o - ,Yjr,
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
ar Double Check Valve 94e.40r ❑ Atmosphere Vacuum Breaker
rr
Manufacturer Size
Model Number <13•`_..) & Located At
Serial Number
The above is certified to be true.
Film Name
Aertified Tester
Firm Addrass ��Y 75 A C4 � ` �,� -a Cert. Tester No. *OD--
Gauge #
Date last accuracy tested /
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 -Clos
Tight 1�
Closed Tight 0(
Leaked ❑
Opened at
osid
Opened at
nsid
nsid
RP -_psid
L ❑
r-�
Z /
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Reps
DC- Closed
Tight a
Closed Tight o
Opened at
osid
Opened at
nsid
n sid
RP sid
The above is certified to be true.
Film Name
Aertified Tester
Firm Addrass ��Y 75 A C4 � ` �,� -a Cert. Tester No. *OD--
Gauge #
Date last accuracy tested /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy