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2011_0222 (4)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: C ► e I I PWS I.D. # LOCATION OF SERVICE: 0 ��n� ©h ��� t`KC}'� • �u ►°�"e (�� 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 Lj (-i -�-C) Size ( +j Model Number 60�-( �`i ,2,- W l Located At EQU l,P me hcorn Serial Number -12 10 7 rl The above is certifiers to be true. Firm Name N Certified Tester S�e- Y f_- s L41 -14 %C . Firm Address ►) �v i I fe "�T �C 750 g Cent Taster No. - 3�''I� Date c� Gauge # _ -- 3706 Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY I 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 osid Tight ❑ Leaked ❑ psid osid RP- i . � psid Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and Materials Used Test Aster DC- Closed Closed Tight ❑ Opened at Opened at osid Repair Tight ❑ psid osid RP sid The above is certifiers to be true. Firm Name N Certified Tester S�e- Y f_- s L41 -14 %C . Firm Address ►) �v i I fe "�T �C 750 g Cent Taster No. - 3�''I� Date c� Gauge # _ -- 3706 Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy