2014_0703 (5) CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAMTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SERVICE: 1:3e H[ nil, ).14z-,
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 0 Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer �.(.�G� Size
Model Number Located At � Vat-
Serial Number lei(. Z
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheek 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed 5 -c Closed Tight Opened at Opened at nsid
Tight JAC Leaked �� Z. o psid psid !!
RP- nSid
Leaked 0 Did not Open 0 Leaked 0
Repairs
and
Materials
Used
Test Afars DC- Closed Closed Tight 0 Opened at Opened at rid
Repair Tight 0 nsid nsid
RP psid
The above is certified to be true.
Firm Name ACf i f:61 cif P pr'c.11S Certified Testa 1.2.2S1%. - OS 7
Firm Address A 450X 79 7 Cert. Tester No. p3Per.) lam/ Date 1-3///
WaW tOchte Tie r).311123
Gau # 06.//0075"
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy