2014_0619 (4) CHECK ONE:
IRRIGATION DO MESTIC 7 ,>( --- FIRELINE
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BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT (� /
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NAME OF PWS: (Cr re m
Cl
PWS I.D. # 1
LOCATION OF SERVICE: // L c.0 t/C. � L Alp . i' M
` p .�r(c S5 r / i �- 5� S .-- �c�`.(yr L -cfCQ
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
o Reduced Pressure Principle 0 Pressure Vacuum Breaker
�� Double Check Valve 0 Atmosphere Vacuum Breaker
MaaufaManufacturer ,- r-� I ' " S Size of
Model Number L 1 4: 1' ' ' � Located At I ex-'1 -- AA e" /
Serial Number UC) � 3 7
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAICER
Double Check Valve Assembly
1st Check 1 2nd Check Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed F" ---- Closed Tight ,gr Opened at Opened at nsid
Tight 6 Leaked a psid nsid
P /J RP- nsid
tJss Leaked 0 Z—. Did not Open 0 Leaked o
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at ___p sid
Repair Tight o nsid nsid
RP *sid
The above is certified to be true. 1�
Firm Name .. (1 i PC b / 1—) Certified Tester -Sc. // 7 - /VI ,, S�(c, -�
Firm Address�°6' � .4 1,- ^ ert
C Tester No. 0 - ---- ` 7
a Date Cn —/-- 9"
fvr y ['Tx 7-S—CIS �'
Gauge # C,U DI Ol
Date last accuracy tested 5 : 5 /Y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy