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CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � C—� L�ca.i�-�ncx�x-
0
PWS I.D. #
LOCATION OF SERVICE: I�I�-� (�A�-v�c�J ��w���Rpe��l� � 7�oI 9
The backtlow 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 Reducrd Pressure Principle o Pressure Vacuimm Breaker
,� Double Chcck Valve ❑ Am�osphere Vacuum Brea�er
Manufact�er �1��, �C iN s Siu �/`,
Modei Ivumber QS o X L. .'L. I,ocated At /.c!V�.�1�-.d� �ei r,� .►r�/ I�t��o c�
�r¢.I►`��' �IP�ss
Serial Ntmiber _�i g Z�.� ?b �e�w►.�` �03� 73b�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double C3eck�alve Assembly
lst Chec3: 2nd Checl: Relief Valve :�ir Inlet Check Valve
Inival Tcst DGClosed Closed Ti�t Opened at Opened at osid
Ti�t �- Leal:ed ❑ psid osid
5s`� Rp- ,�o sid a.g
�;� ❑ Did not Opea ❑ Leal:ed ❑
�P�
and
Mataials
Used
Test Afttr DGClosed Closed Tight o Opened at Opcned at �sid
Repair Tight o osid osid
RP sid
The above is certified to be we.
Firm Namc � � Certifiod Testa ,�a-�, �. i�.,i�
�
Fum Address h�f��'/l7ia r�i.r t .u,!G'..J Cert. Tes[a No.�`�xx�2�3 l Date/b /y
/C u � 7L tS/5�
Gauge # ��07<7��
llate last accuracy tested 7 /�1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy