2012_0420 (8)CHECK ONE: ,/�
IRRIGATION /t/ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSE1rIBLY TEST' AND MAINTENANCE REPORT
NAME OF PWS: L � ? ` G' F�
PWS I.D. # � K T
LOCATION OF SERVICE: �'Lfi1C� ,J t � � d e`-'+ d
The back }low prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Reduced Pressure Principle � Pressure VaR*+*+*� Breaker
Double Check Valve o Atmosphere Vacuum Brew
Manufacturer �C`w. i7 5 $iJP (�/, ;
Model Number ^i, of �� i Located Az w+ � `T �'� G 5 Tt%Lc.r i
Serial Number A � 6 � 3 C7
The above is certified to be true. )/ r5
Firm Name A AG T c v aJ tj ' tfr_ Certified Tesce � GJ c� h c IsJ rt' v� y� [�
Firm Address � C7 i>O)C � i % Le%�C'ic.1„ ee�...CerL Tessa No. !U Pd o a cis %3 Date `� ��� l
Gauge # 3� °l C7/
Date Iast accuracy tested � �(/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI�LSLY
PRESSURE VACUUM BRE_A�'F'R
Double Cherie Valve Assembly
1st Chec]:
tad Check
Relief Valve
Air Islet
Check Valve
lainal Test
DC- Closed
Closed Tight �7
Opined at
Opined at
nsid
Ti�it �_ (o �D
RP- nsid
Leaked o
f - �►
nsid
_ asid
Leaked o
Did not Open �
Leaked a
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opined at
Opined at
nsid
Repair
Tight �
nsid
nsid
RP std
The above is certified to be true. )/ r5
Firm Name A AG T c v aJ tj ' tfr_ Certified Tesce � GJ c� h c IsJ rt' v� y� [�
Firm Address � C7 i>O)C � i % Le%�C'ic.1„ ee�...CerL Tessa No. !U Pd o a cis %3 Date `� ��� l
Gauge # 3� °l C7/
Date Iast accuracy tested � �(/
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy