2013_0919_RPZ (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIO'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
ev
PWS I.D. #
LOCATION OF SERVICE. Mal` I'll
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 1 s Sizei�
Model Number LAM 'D'— Located At � ►"�- � �
Serial Number NO 1 I-) [ iaj-eJ
The above is certified to be true.
Firm Name ] x e i) Rt,e-., Certified Testa Adam
Firm Address C r iii Cert. Testa No. t~ Date 9119113
Gauge # 3 ?71 q G
Date last accuracy tested [ j
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
psid
nsid
RP -_psid
Leaked
Did not Open ❑
Leaked ❑
Repairs
Ce,pUu a r
and
corypto"Q+
Materials
4% �c)F�t'
Used
Test After
DC- Closed
Closed Tight
Opened at
Opened at
_nsid
Repair
Tight zo,
`
sid
nsid
RP sid
The above is certified to be true.
Firm Name ] x e i) Rt,e-., Certified Testa Adam
Firm Address C r iii Cert. Testa No. t~ Date 9119113
Gauge # 3 ?71 q G
Date last accuracy tested [ j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy