2011_0222 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: ? �"v Ca�(JE f
PWS I.D. #
LOCATION OF SERVICE: ?)0 %(. —Dentn r
T
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 `, t T _ Size
Model Number Located At
:.:
Serial Number 1r?a�
The above is certified to be true.
Firm Name
�.Se��Certified Tester
►mac
Firm Address i 1` e . (X 7 a�Cert. Tester No �w^,I -�7A Date —I I
Gauge # -1 ^ r
Date last accuracy tested 1 —10
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 ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
nsid
n-Sid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name
�.Se��Certified Tester
►mac
Firm Address i 1` e . (X 7 a�Cert. Tester No �w^,I -�7A Date —I I
Gauge # -1 ^ r
Date last accuracy tested 1 —10
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy