2011_0212CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C o
PWS I.D. #
LOCATION OF SERVICE: IDS J • c,� J �c� ���Y
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 Size
Model Number i _ Located At L, e ► -e,,4 D- ic V
Serial Number
The above is certified to be true.
Firm Name Certified Tester --
Firm Address -7', 4 - <,f-4`',4- C_-E4r 1-a-A ,, " Cert. Tester No,
Gauge #
Date last accuracy tested
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 A�
Opened at
Opened at
psid
0
Tight O
RP -_psid
Leaked O
Leaked O
~/
psid
osid
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester --
Firm Address -7', 4 - <,f-4`',4- C_-E4r 1-a-A ,, " Cert. Tester No,
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy