2014_0121_RPZCHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PWS I.D. #
LOCATION OF SERVICE: 61
as 5 Ic . 4-Y 1 2- 1 14-- /D o
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.
XReduced Pressure Principle
❑ Double Check Valve
Manufacturer w S
Model Number 9 7 6 X L
Serial Number 3 q- S 795
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
ZZ
Size �
Located At zj%4 +r �✓ ��D s
The above is certified to be true.
Firm Name kt
Certified Tester 1<4 5 fY /u rn t-r
Firm Address jf�f "✓ k i 7X 7(0 pkem Tester No. 4 D Z3 / Date
Gauge # D l0 070.66 9
Date last accuracy tested '330'1-3
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
05"7
DC- Closed
Tight
RP —„psid
Closed Tight
Leaked ❑
g.
. ed at
psid
Opened at
oSid
oSid
Leaked ❑
Did not Open ❑
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 kt
Certified Tester 1<4 5 fY /u rn t-r
Firm Address jf�f "✓ k i 7X 7(0 pkem Tester No. 4 D Z3 / Date
Gauge # D l0 070.66 9
Date last accuracy tested '330'1-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy