2013_0514_RPZ (3)CIIECK ONE:
IRRIGATION
DOMESTIC ✓
FIRELINE
BACKIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE:
0
The backflow prevention assem ly detailed below has be 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 W ; /< </ r7 S Size
Model Number 375 Located At
Serial Number A 0 g q ! J<&
9, 54 r R-00 -t
The above is certified to be true. ,' J
Firm Name A411 Certified Tester -7—y le r (v,
Firm Address ��� /� �•� �i�� 0 5 at / l
Ccrt. Tester No. R Pl0 De
te 3
Gauge # 6)(207/25W
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
Air Inlet
Check Valve
Initial Test
4 g tj
DC- Closed
Tight -
RP -nsid
Closed Tight ❑
Leaked
Opened at
3 • a- psid
Opened at
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true. ,' J
Firm Name A411 Certified Tester -7—y le r (v,
Firm Address ��� /� �•� �i�� 0 5 at / l
Ccrt. Tester No. R Pl0 De
te 3
Gauge # 6)(207/25W
Date last accuracy tested 7-16 /Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy