Freeport NIP(8.0)-LR050215CHECK ONE:
IRRIGATION
BACKFI,OW PREVEIVFION .43SEMBLy TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS LD. #
LOCATION OF SERViC~
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 Pre-utc Vac~m Bresl~
o A.m~-p~ Vac~m Bl'~kcr
$i2e ,:~ o
REDUCED PRESSURE PRIN~ ASSEMBLY' PRESSURE VACUUM BREAKER
Do~a O,~ V~a~m~
~.tc~,, ~.o 2~c~.~:'.~ ~.eae~V~,e airh~, ~V~
Ti~ ~ ~ o ~ ~
U~
Date last accuracy tested,
White - Customers Copy Yellow - City CoLay PiRk - Tester~ Copy
IRRIGATION
PWS I.D. #
mc^no oF,sn - C;
The backflow prevention assembly deiailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters,
Manufaa~r
Number
Numar
Double C~,~-~ Valve
TI~ above is cm~d to be m~..
Gauge # oo ~z-o-~'
Date last accuracy te~ted _~ ~ -3 I- t~
White - Customer~ Copy Yellow - City Copy Pink - Tester~ Copy
CHRCK ONE:
IRRIGATION
~-v'~.~ r .~..~ ::
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
PWS:
PWS I.D. #
LOCATION OF SERVICE:
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.
Manufacturer
Model Number
Serisl Number
Reduced Pr~sure Pr:mciple
Double Cl~k Valve
TYPE OF ASSEMBLY
m Pr~sure Vacuum Brealm-
m Almosphere Vacuum Bm~
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAIOgR
Double Che~ Valve Assembly
lstCheck 2,~ 2ndCbeck~V.O Rf. liefValve AirInlet CaeckValve
Initial Test DC-Clos~ F~IOs~ Tight ~ 'Opened at Opened at psid
Ti~t ~ Leaked 0 psid psid
~-/ PP- psid
Leaked m Did uot Open ~ I.~aked ~
MatmaLs
Used
Test After DC-Closed Closed Ti~t ~ Opened at Opened at psid
R~alr Tight m psid psid
PP psid
The above is certified to be true.
FirmAdd~c~s 22.V'a t~e~--~,~ 2d>~ert. Te~rNo~P~/.X'TDate ~'/$7°-f''~'
Gauge # ~>2--~C'~
Date last accuracy tested ..~- Z/-/~--O_.C~
White - Customer~ Copy Yellow - City Copy Pink - Tester~ Copy
CHECK ONE:
IRRIGATION DOMESTIC FI. RELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSI~V[BLY
Manufacturer
Model Number
Sm'iai Number
Pressme Vacm~ Brraker
A~mospher~ Vacuum Br~l~r
Z"
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACIKIM BREAKER
Double Check Vslve Assembly
ls~Check ~,~2 ~!ndCheck~-/~ RellefVlflve A/tinier CheckV~lve °
Initial T~ DC-Clos~ ~Clos~d Tigh~ ~ ~med at Opened at psid
Ti!~ ~' Leak~ 0 psid psid
Lr. akcd o Did not Open o Losked ~
Materials
Used
Test 3d~cr DC-Closed Closed Tight o Opened at Ol~ncd at p$id
Repair , Tight O psid psid
RP psid
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester~ Copy