2013_0514_RPZ (2)CHECK ONE:
IRRIGATION
DOMESTIC ✓ FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 0 _ i , � y 0 � Co e l f
PWS I.D. #
LOCATION OF SERVICE:
/ q 5 4q s. ,6P1� /i /I,� ,eo!
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 Gt'R I+ Size LW I
Model Number 009073 Located At 54 oG k- P,,0 o X4
Serial Number 3 (P a ?O T
The above is certified to be true.
Firm Name Hal /Q .S4 Certified Tester
Firm Address /lea j1J; a /-& Oet t. Tester No.R_P!_'0_lT6 Date
Gt%r t, T! `oZyy
Gauge # V6 o 7/-78
Date last accuracy tested 7 16 ` /Z.
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
:fir Inlet
Check Valve
Initial Test
?rl 55
DC- Closed
Tight )6
RP-_psid
Leaked ❑
Closed Tight �f_
Leaked ❑
9 .
Opened at
�� psid
Opened at
oSid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name Hal /Q .S4 Certified Tester
Firm Address /lea j1J; a /-& Oet t. Tester No.R_P!_'0_lT6 Date
Gt%r t, T! `oZyy
Gauge # V6 o 7/-78
Date last accuracy tested 7 16 ` /Z.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy