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2012_0420 (6)CHECK ONE: IRRIGATION__ DOMESTIC FIRELINE BACK.FLOW PREVENTION ASSEMBLY TEST' AND MAII�ITENANCE REPORT NAME OF PWS. �- � ? `� L'' � Lc�T� -t/ PWS I.D. � � C., %L-� LOCATION OF SERVICE: ��� f--�f Y t CS ��y The backflow prevention assembly detailed belo�� has been tested and maintained as required by TCEQ rem =ulations and is certiYicd to be operating within acceptable parameters. TYPE OF ASSEMBLY o Reduc. -d Pressure Principle C Pressure Var*�***+ Breaker � Doubie Check Valve � Atmosphere Vacuum Breaker Manufacturer �Q� T T'S $ j7P a "' Model Number ^ ©O 7 ✓N ( Located At (� VN1 � .T �'�' O-✓ /i%- S t o� � Serial Number � a 6 6 t� � The above is certified to be true_ y-� S Firm Name � � T �G�-J �i �� Film Address b0'7 h�l I Gage # 3 � `�! / � Date last accuracy tested � J C / Certified Tcste /�n Lt�G �� ✓� r_ � L° K N ®/ Cent Testa No. � r PC�c� c/ `��3 Date ���e�/ � White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Checl: 2nd Cheri: Relief Valve ?►ir Inlet Cheek Valve Itzitial Test DC -Clos� Closed Tight ,lI9 Opened at Opened at nsid Tit %. " �! RP- nsid Leaked � y o nsid nsid Leaked o Did not Opea o Leaked D Repairs and Materials Used Test Ages DC- Closed Closed Tight o Opined at Opined at nsid Repai; Tight a nsid nsid . RP sid The above is certified to be true_ y-� S Firm Name � � T �G�-J �i �� Film Address b0'7 h�l I Gage # 3 � `�! / � Date last accuracy tested � J C / Certified Tcste /�n Lt�G �� ✓� r_ � L° K N ®/ Cent Testa No. � r PC�c� c/ `��3 Date ���e�/ � White - Customer's Copy Yellow -City Copy Pink - Tester's Copy