2011_0330 (4)CHECK ONE:
IRRIGATION
DOMESTIC X
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: / A
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.
Reduced Pressure Principle
❑ Double Check Valve
Manufacturer 10A K S
Model Number
Serial Number N n
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size t
Located At : A(k P rynn D �
`C'P deur <_-
The above is certified to be true.
/ J
Firm Name I)�s Alut -n C ' ' I-'k1reCmtified Tests °t
Firm Address Cert. Testa No. Date
n 1('
Gauge # 640," 174V
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 *
Opened at
Opened at
osid
Tight ❑
RP - t Dsid
Leaked ❑
psid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
/ J
Firm Name I)�s Alut -n C ' ' I-'k1reCmtified Tests °t
Firm Address Cert. Testa No. Date
n 1('
Gauge # 640," 174V
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy