2014_0703 (2) CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT { `
NAME OF PWS: Afi
PWS /�'/
LOCATION OF SERVICE= eo I lien mm/lnK,
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 Vacunn Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 14)4f Size
5 o,
Model Number 77V Located At C� eel 1 ? Y' , Ul ✓4..1.t. �`—
Serial Number 0-
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRFSiCER
Double Check Valve Assembly
1st Cheek 2nd Cheri: Relief Valve Air Inlet Check Valve
- - - - -- -- - - - --- -- - --
Initial Test DC- Closed Z b Closed Tight Opened at Opened at nsid
Tight :19( Leaked ‘Z_ (e, ❑ nsid nsid
RP- nsid
Leased ❑ Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used E
Test After DC- Closed Closed Ti O
Tight Opened at Opened at
Repair Tight ❑ _ nsid nsid
RP • sid
The above is // certified to be true. A
Firm Name 401 /4 D7 fir-e l -fi S Certified Tester id/i29)
1/ 5 TC �:
Firm Address 1 Cent Tester No. /3PL fG�6.�5 /. Date � // f ttxtchu C-1 - re .15i(06
Gau # ( /za/77
Date Last accuracy tested 91,43
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy