St Ann Catholic-LR011008 (3)CtIECK ONE:
IRRIGATION
-- -- DOMESTIC
~ F/RELINE._~/~)__~
BACKFLOW PR~ VENTION ASSEMBLy TEST AND MAINTENANCE REPORT
PWS I.D. #
LOCATION OF SERVICE: ~
The backflow prevention assembly detailed below has bee~ test~ and
r%en!~-_'ons and is cer~ed to be ope~'ating ~thin acceptable parameters, maintained as r~qui~I by. TNRCC
Reduced Pressure Principle
Double Ch~ck Valve
Manufacturer /eficQ
Serial Ntmaber U,4/~ ~ ~
Im~ial Tes~
Materials
Used
T~'t A.ear
Double Check Va/ye Assembly
TYPE OF ASSEMBLY
Pressur~ Vacuum Breaker
[] Armospher~ Vacuum Breaker
Size
Located At
1st Check
'DC-Closed
Tight t, 5-
RP- psid
2nd Check
Closed Tight
Leaked
Closed Tight
DC-Closed
Tight
The above is c.~hfied to be true.
Relief Valve
Opined at
-- psid
Opted at
- _psid
.Mr Inlet
Opted at
-- psid
Did not Open 0
Opted at
----_._~psid
Check Valve
psid
-- ~psid
Cer~ Tester No. ~am
White - Customer,s Copy Yellow - City Copy Pink - Tester's Copy