2014_0424 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE � �.y1 � , ,� ��
t�
BACT{FZOW PREVENTION ASSEMBLY TEST AND MA.Il�TI'ENANCE REPORT
NAME OFPWS: L� ?`/ G''F� !r_��Pt - I/
PWS I.D. #
LOCATION OF SERVICE: 3c� � i4 . rc... � (�.r
The backllow prevention assembly detailed belov`� has been tested and maintained as required by TCEQ
regulations and is certifiied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle C Pressurc Va nn_++*+ Breaks
Double Check Valve o Atmosphere Vacuum Breaker
JA �G AA � r
Manufactaaer i.tic. T i Size c
Model Number 7 e� �i Located At l.�cxe � T . -.� C %.i.n i
Serial Number r / S 7dv <<-'� Sid e
Date IasY accuracy tested 3 /�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B REAKE R
Double Check
Valve Assembly
1st Checl:
tad Chec3: Relief Valve
Air Inlet Check Valve
Initial Test
DC- Closed
Closed Tight � Opened at
Opened at n sid
/��
Tit
o
Lcalcd C] n sid
n sid
3� /�
RP ns i d
Lcak
o
Did not Opea O Leaked v
and a'.t
� T � /.4cc - I'}n
_ -�� � �
Matc
Used
Test ARer
DC- Closed
Closed Tigjat � Opened at
Opened at n sid
Rcparr
�5 a
�'
�, � n sid
n sid
R id
The above is certified to be true-
y � 5
Firm Name �C'T•u.n
G �
Certified Testa I�JGcAc��
,�. c W � n v� +�
Firm Address
�� �i� °� .0 7�j '7
�t/c ,c °T y Cent Tessa No. � cry
�'i � a S Date � �� ` /� `
'75( Gad}
Gauge # O
� U: ^-� �7id � G�
Date IasY accuracy tested 3 /�
White - Customer's Copy Yellow -City Copy Pink - Testers Copy