2014_0121CIIECK ONE:
IRRIGATION DOMESTIC x
FIRELIN E
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
PWS I.D. #
C0oOa-t t
LOCATION OF SERVICE:
as 5 .may
/2/ -7.
The backflow prevention assembly detalle below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number
Serial Number 7 (0 2-
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 1Y.2,
Located At 4;Pr
The above is certified to be true.
Firm Name A i I S+
Firm Address r4, L leA, %7C 7&2 -'Ifl
Gauge # DlpO7054p6
Date last accuracy tested
Certified Testa KO-S-e-V /urn -e r
Cert. Tester No. 6 0la2M Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
S
DC- Closed
Tight
RP -�psid
Leafed ❑
Closed Tight
Leaked ❑
., 5 G
Cened at
0 psid
Opened at
nsid
Did not Open o
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight Cl
nsid
nsid
RP sid
The above is certified to be true.
Firm Name A i I S+
Firm Address r4, L leA, %7C 7&2 -'Ifl
Gauge # DlpO7054p6
Date last accuracy tested
Certified Testa KO-S-e-V /urn -e r
Cert. Tester No. 6 0la2M Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy