2014_0703 (6) CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT 9
NAME OF PWS. � `f L' ���C - /
PWS I.D. #
LOCATION OF SERVICE 80, Ha f'YOW/4e../
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 Vain+**+ Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer (atOA Size / ' Y /
Model Number ea 7,4/ Located At �-
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheek 2nd Cheek Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed .2 -6 Closed Tight p¢' Opened at Opened at vsid
Tight jlie Leaked 2_ 6, o psid �sid
RP- vsid
Leaked o Did not Open o Leaked o
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at __psid
Repair Tight o vsid vsid
RP psid
The above is certified to be true. //
Film Name e4-4ie)
C dl 1 r L' S Certified Tester . atit cO f? IX'S`MAI
Firm Address Jor.) 77q 7 Cert. Testa No. /3/trlei., Date T/0/� f
Gau # U (p f /ex, 5 J
Date last accuracy tested -7/5 3
White - Customer's Copy Yellow - City Copy Pinlc - Tester's Copy