2011_0222 (3)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C t h/ i
PWS I.D. #
LOCATION OF SERVICE: at J� O . �U e nA-0 (\T;'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 (j ) 19 T 11 -S Size
Model Number Located At � t a
Serial Number
� 7-,,-7 1, a4
The above is certified to be true.
Firm Name i-si r<GC�t i ,L�`gcertified Tester r -
Firm Address -eu3i SYi!< �X 5Q.P9 Cert. Tester No.
Gauge # _137(77. 1! 1. , r
Date last accuracy tested 3— ( " I()
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
Tight " ❑
RP- 7. a psid
Closed Tight ❑
Leaked ❑
Opened at
gsid
Opened at
psid
psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name i-si r<GC�t i ,L�`gcertified Tester r -
Firm Address -eu3i SYi!< �X 5Q.P9 Cert. Tester No.
Gauge # _137(77. 1! 1. , r
Date last accuracy tested 3— ( " I()
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy