2014_0703 CHECK ONE:
IRRIGA TIO N
DOMESTIC FIREI.INE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: L, - r1 or rc,pPr /!
PWS I.D. #
LOCATION OF SERVICE: 63/ ?, LS. dejva
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operatine within acceptable parameters.
TYPE OF ASSEIVIBLY
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size 2 if
Model Number er7�7. Located At C7e7 " v
Serial. Number X373 Zz.
REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACUUM BREAK'E'R
Doubie Check Valve Assembly
1st Cheek 2nd Cheek Relief Valve Air Inlet Check Valve
Initial Test DC- Closed 2 - 2 Closed Tight Opened at Opened at nsid I
Tight ,14 Leaked 0 nsid psid
RP- osid `z - 5`
Leaked o Did not Open o Leaked o
Repairs
and
Materials
Used
I
Test After DC- Closed Closed Tight o Open at Opened at psid j
Repair Tight o sid paid
RP • sid
The above is AA certified to be true. / �///
Firm Name Hl;47ny [�R
� 1 YP_ Ca5 Certified Tester liz Sd y llus -ro nl
Firm Address O o __ Z- 7 7 `i( A�S� {t Cert_ Tester No. p&001 ObSL Date
�S iLA)
Gau # dro /600 75
Date Last accuracy tested 1/43
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy