2013_0919_RPZ (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: G hi 0 ( C,() 1' b.PJj,
PWS I.D. #
LOCATION OF SERVICE: �,;+• Ma /Iii
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
Manufacturer (kh Size
01,11
Model Number c�"' Located At
Serial Number '0)-0 <? �p I
The above is certified to be true.
Firm Name.Daw 6, 1) h CC/ Certified Tester Adam
Firm Cem Testa No
Gauge # i a---I q Lp
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- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
nsid
nsid
RP -_psid
Leaked
Did not Open ❑
Leaked ❑
Repairs
t'9Ab�P
and Materials
c�p O�
Used
f 7b ip 9 et
Test After
DC- Closed
Closed Tight F(
Opened at
Opened at
nsid
Repair
Tight
RP �'` sid
t ° 4
a- sid
nsid
The above is certified to be true.
Firm Name.Daw 6, 1) h CC/ Certified Tester Adam
Firm Cem Testa No
Gauge # i a---I q Lp
Date last accuracy tested '
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy