2014_0619 (2) CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACT{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C C5 C / '
PWS I.D. #
LOCATION OF SERVICE: � ! _ . l/ z./ C � f t - 1/1cr
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 Vac-uu*n Breaker
/ ®C Double Check Valve Atmosphere Vacuum Breaker
11 Ii
Manufacturer 1 r Size
Model Number 7 5 C) / A Located At � �G / l , ( �
Serial Number 1! - 3 Pi v
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 1 2nd Cheri: Relief Valve Air Inlet Cheek Valve
Initial Test DC- Closed q-J Closed Tight `ji Opened at Opened at psid
Tight '"pe Leaked 0 psid _psid
9 4-.S 3 Leaked o T d Did not Open o Leaked o
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight a Opened at Opened at nsid
Repair Tight _psid _psid
RP psid _
The above is certified to be true. J
Firm Name it) . l Pz � Ge " e / - Its) Certified Tester 97- / r/ /�
4 " S
s
Firm Address � �
61 F Cf � `^ Cert ^
Tester No. �/ Date
7 Svc
Gauge # O U o 3
Date last accuracy tested f /�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy