2011_0330 (5)C' p /o - �)a' �
CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: I N lz> i
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 Vacuinn Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer I + ) A4 c
Model Number _
serial Number !'
Size
Located At SAC IBC itcd w, b t�
awd &.Vkce
The above is certified to be true.
Firm Name �.1 jS t�n".13A�� /� Certified Tester L�Q ti
Firm Address Va.vk bJ1 /! lALI n. y�2 Cert. Tester No. ?/°�o&3 ,�,� s, Date Is
C'14 & n � /�oN/ 7-s -
Gauge # 0,16 c � / `- `'
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 ❑
Leaked ❑
psid
osid
RP- _psid
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.
Firm Name �.1 jS t�n".13A�� /� Certified Tester L�Q ti
Firm Address Va.vk bJ1 /! lALI n. y�2 Cert. Tester No. ?/°�o&3 ,�,� s, Date Is
C'14 & n � /�oN/ 7-s -
Gauge # 0,16 c � / `- `'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy