2014_0703 CIIECK ONE:
IRRIGATION h DOMESTIC FIRELINE
BACI FLOW PREVEN'T'ION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME of Pws : c: , •T I 4" F' Cc f � F' ,° / y ��
b
PWS I.D. # c err:. &
LOCATION OF SERVICE:
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 Va.-..um Breaker
Manufacturer /A.,/ • ? Size Z s+
Model Number caf9 7,4-4 Located At c_514J
Serial Number O q 2-
REDUCED PRESSURE. PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAP:ER
1
Double Cheek Valve Assembly
1st Cheek tad Cheek Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight ,/ef Opened at Opened at nsid
Tight— e) 12C.: Leaked
❑ nsid nsid
RP- L trsid /. e
Leaked o Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used
Test After DC- Closed Closod Tight a Opened at Opened at nsid
Repair Tight ❑ nsid aid
RP • sid
The above is // certified to be true. ! 1 �
Firm Name �` o_`E l !�'r'1 Y l Y -e �� e`?5 Certified Tester LI �S G r l t- fC✓.C' TO to
Firm Address J0Q �X 74 7 Cert. Tester No. �f'/ 1 Date . 7/: / % c,
6VezzCe h&c It Lc_ 151 LOS
Gauge # t"Vl� /lrJ‘") 7s"
Date last accuracy tested f/6`,(F
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy