2012_0420CHECK ON1;:
IR RIG A TIO N
DOMESTIC
FIRELINE N
BACKFLOW PREVENTION ASSEMBLY TEST' AND MAINTENANCE REPORT
NAME OFPWS: L-i ?�f G'f� Lcn�rt/
Pws I -D. # 1'�J �-�
LOCATION OF SERVICE: � -jC.7y !-� a >J � � eH d
The buckflow prevention assembly detailed below• has been tested and maintained as required by TCEQ
re < < ^ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle n Pressure Va�-cn_+*n Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacnzter li(ia � 7 S Size 3��%
Model2Nimmber Do`7 W� a-
Serial Number % � S r%
Located At /��U � �� l�Gca Z �
The above is certified to be true. �/� �j
Fitm Name A (C� � /(2�. --% �t �' c Certified Tcste g4 �� (aJG�� �nP (J�% C �n yl �i'
Firm Address �O !� O 3[ ? 9 7 Cert_ Testa No. C91'tscx�ct `i � >' Date ` I ���� � �
wG.?CG. y�aGinit
Gat:ge # 3 � LI �; / i3
llate Iasi accuracy tested � / //
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEi�iBLY
PRESSURE VACLJCIM BREAKER
Double Cher3c Valve Assembly
1st Chen:
2nd Checl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tilt �. '-� �9
Closed Tight ,�
Lcal:cd �, s� D
Opened at
psid
Opened at
nsid
nsid
RP- nsid
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opined at
nsid
Repair
Tighe o
nsid
nsid
RP sid
The above is certified to be true. �/� �j
Fitm Name A (C� � /(2�. --% �t �' c Certified Tcste g4 �� (aJG�� �nP (J�% C �n yl �i'
Firm Address �O !� O 3[ ? 9 7 Cert_ Testa No. C91'tscx�ct `i � >' Date ` I ���� � �
wG.?CG. y�aGinit
Gat:ge # 3 � LI �; / i3
llate Iasi accuracy tested � / //
White - Customer's Copy Yellow -City Copy Pink - Testers Copy