2014_0619 CHECK ONE:
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BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT 3)
NAME OF PWS: � u e P e l � `-
PWS I.D. # 1
LOCATION OF SERVICE: 77'1" e Incse 0 L CS$c] t / /S S'� Sc
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
CJ Reduced Pressure Principle a Pressure Vacuum Breaker
�° Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
\.* = r.S Size
Model Number 3 V Located At Y e �Cr
Serial Number A- 3 - 7 a
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheek 1 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed 2 � - Closed Tight )13 Opened at Opened at nsid
Tight 7d Leaked o nsid nsid
RP- nsid
QA SS Leaked Did not Open O Leaked o
Reps
and
Materials
Used
Test Ages DC- Closed Closed Tight O Opened at Opened at nsid
Repair Tight nsid nsid
RP psid
The above is certified to be true.
Firm Namee0o t P r a 13,,, ���v� Certified Tester _ a - tM G --"(
Firm Address S Av Cr 4 I,— Cert. Tester No. S -3 X Date � - �1 --/y"
— c - -/r'fk 7_3 G S�
Gauge # d 6 U L. 7
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy