2012_1009_RPZCHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ���"y 4�-,OONI(
PWS I.D. #
LOCATION OF SERVICE: � 03
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
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
ry
Manufacturer �°✓�� Size
Model Number C1 Q It Located At
Serial Number
The above is certified to be true. yr-,
Firm Name P.56 Fl fci 46 V -a ?d Certified Tester
Firm Address pa Cert. Testa No, Date / 6 'T Z
Gauge # AI- 91 --Illf
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
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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
Opened at
Opened at
nsid
Ti t4
RP -_' ,psid
Leaked ❑
psid
nsid
Leaked C
Did not Open ❑
Leaked ❑
EAfterDC�-Closed
Closed Tight ❑
Opened at
Opened at
nsid
❑
psid
nsid
sid
The above is certified to be true. yr-,
Firm Name P.56 Fl fci 46 V -a ?d Certified Tester
Firm Address pa Cert. Testa No, Date / 6 'T Z
Gauge # AI- 91 --Illf
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
r ,p