2011_1017 (2)CHECK ONE-.
IRRIGATION DOMESTIC FIRELINE
BAMLOW PREVENTION AMEMLY TEST AND MARaViANCE REPORT
NAME OF PWS: GLOP e'
PWS LD.
LOCATION OF SERVII
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.
o Reduced Pressure Principle
Double Check Valve
Manufacturer AL�
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacutmr Breaker
o Atmosphere Vacuum Breaker
Size
Located At A16 ' G""`""-"
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check Z, a Znd Check I� � Relief i%alve Air Inlet Check Valve
e Opened At Opened at _� sid
Initial Test DC- Closed Leaked Op
Tight ❑ Psid _. nsid
R.p-- ---Psid Did not Open 0 Leaked 0
Leaked ❑
Repair
and
Materials
Used osid
Closed Tight o Opened at Opened at
Test After DC- Closed osid osid
Repair Tight o
Rp sid
The above is certified to be true.
Fires Name
Firm Addmess 17e Br i 7 T 7
Wqk, -T'V- -7 ,9)6$
Gauge # 07 04121 LEY
Date Last accuracy tested O - / ' / ,
Certified Tester k ,"&P -j i. Cogf) ?�
Cent Tester No. i5 Pc w Date J ' - i z- j I
white - customer's Copy
Yellow - City COPY Pink - Tester's COPY