2012_0420 (4)CIIECIi ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST' AND MAINTENANCE REPORT
NAME OF PWS: L �_T ` G' F-
PWS LD. # Y-c
LOCATION OF SERVICE: Ll �� � j `� 1 d 'r"� d
The backl�ow 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
D Rrsluccd Pressure Principle c Pressure Va�-+*+�**+ Breaker
Double Chock Valve o Atmosphere Vacuum Breaks
Maaufacttu�er ��14 '� i S Size 3�`�
Model Number C'C� �7 1'�1 �- Located At � � V � v L T �� �� �eJ a
Serial Number ' l� � � � 6
The above is certif ed to be true. � .P �l
Firm Name T/v :^ � � Certified Tester �pp—D, �r�� w e W -P in v� e-�
Firm Address i �� iC % � � Cert Testa No. I�iPOc�9yo,� Date `� ��' ��
G1CGL. Nc GY►.�
Gauge # 3 `% � C`7 ��
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT.�F'R
Double Check Valve Assembly
Ist Chec1:
2nd Chec3:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Ti�tt lID
Opened at
Opened at
nsid
Ti�at � f.% tlkD
RP- nsid
Leaked � c4 O
nsid
nsid
Leaked D
Did not Open o
Leaked �
Repaus
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight �
nsid
nsid
RP sid
The above is certif ed to be true. � .P �l
Firm Name T/v :^ � � Certified Tester �pp—D, �r�� w e W -P in v� e-�
Firm Address i �� iC % � � Cert Testa No. I�iPOc�9yo,� Date `� ��' ��
G1CGL. Nc GY►.�
Gauge # 3 `% � C`7 ��
Date last accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy