2014_0703 (3) CHECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACKFL.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: _ T � / G' l-^ f-c ! P r / /
PWS I.D. #
LOCATION OF SERVICE: 4 0I y4 1441.4.4r4 rid
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
0 Reduced Pressure Principle O Pressure Vacuum Breaker
.5<' Double Cheek Valve o Atmosphere Vacuum Breaker
Manufacturer 0.40 "ti S Size
Model Number r ein 7/14 Located At . Sn vaa. t er /j
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAICER
Double Check Valve Assembly •
1st Check 2nd Check Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed 2 Z Closed Tight A Opened at Opened at nsid
Tight I( Leaked ,z . o __nsid nsid
RP- vsid
Leaked C7 Did not Open O Leaked O
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight n Opened at Opened at nsid
Repair Tight Q nsid nsid
RP • sid
The above is certified to be true. /�
Firm Name �! 100 C II�Q 0.-G15 Certified Tester is A',S /)
Firm Address ,0 A2k 7 Cert. Tester No. ect20421.a51 Date `7 /�9/V
tai,X4I/QG h ie T r / 15i co Vi
Gauge # //e2/7/7.5'
Date last accuracy tested C
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy