2016_0503 C�IECK �NE:
IRRIGATION� DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � �' ��e
PWS I.D. #
LOCATION OF SERVICE: C� y� ��,���-�
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 o Pressure Vacuimm Brcakcr
O�Double Check Valve ❑ Amaosphere Vacuum Breal:er
Manufact�uer i��-e� Size f�J�LJ
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Model Number �� Located At ���CL�J
Scrial Ni�bcr �"�2 7� �
,
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Valve Assembly
lst Chec]: �nd Checi: Relief Valve Air Inlet Check Valve
Inival Test DC-Closed Closed Ti;ht r6 Opeaed at en a '
Ti Leal:ed ❑ psid
RP��psid �.�j
P
Lcal:od ❑ , � not Open O L;�al:ed o
RtPairs
and
Materials
Uscd �
Test After DGClosed Closed Tight o Opened at Opeacd at nsid
Repair Tight ❑ __psid osid
RP sid - � �.�
The above is c«tifiod to be tcue. �
Fum Name � Certified Tcsta ���
Firm Address � /� l 1 C�����1 Cert. Tester Na 'SZ'��� Date 5 ' 3=��
Gauge # J?�'�t��2� .� ..
llate last accuracy tested 7 ^���1 j�
White - Customer's Copy Yellow - City Copy .;. Pink - Tester's Copy
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