2014_0619 (3) CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACK:FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: rape
pe t l
PWS I.D. #
LOCATION OF SERVICE: /C . / C e I C SS o ! l S�� : ce ~ /-{ `' e
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 Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer tc-.) C Size " Vy- h
Model Number S L � Located At � � ' r- / .20
Serial Number �� � _S 10)c)—
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 1 2nd Cheek _ Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at _psid
Tight Leaked CI psid _psid
RP- nsid
Lcaked n Did not Open o Leaked �
Repairs •
and
Materials
Used
Test After DC- Closed Closed Tight 0 Opened at Opened at nsid
Repair Tight nsid nsid
RP psid
The above is certified to be true. / M
Firm Name 0 i P/� � �lsc� Certified Tester � �� � / f ' ` J �S°'rlY�
Firm Address -S tA ti L` 4 Cert. Tester No. 3 S7 > Date
1>c
G auge # eDC� J d
Date last accuracy tested /`jc
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy