2012_0316CilL•'C3K ONEz
IRRIGATION
DOMESTIC
FIi2li.IIVE �
BACKFLOW PREVENTION ASSEIVIBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L- i .7 �� G'y �- Lr, (J �..-!1
PWS I -D. # ff
LOCATION OF SERVICE: � bJ O T �% 1 d c.�
The backtic:>cv prevention assembly detailed below has been tested and maintained as required by TCFQ
regulations and is certified to be operating within acceptable parameters -
n Rcducad Pressure Priaciplc TYPE OF AS�SEMB fissure Vac+++*++• Breaker
{��- Double Check Valve o Atmosphere Vacuum Breaker
Maaufaczurer k.�-? ^7 5 Size _ J O
Model Number / �� °� tJC p0.- Located At �__ /� �� � L T � ' j IYLr c''
Serial Number l � U �%o� 1
REDUCED PRESSURE PRINCIPLE .ASSEMBLY I PRESSURE VACiTLTM BRFaKFR
Double Check Valve Assembly
ist Check._ 77 , / tad Cbeck Relief Valve Air Inlet Check Valve
Initial Tesi DC- Closed�7 "f Closed Tigh� �l Cpeaed at Opened ac nsid
Tight T2! Leaked ni o _psid nsid
RP- nsid
Leaked c Did noc Open o Leaked D
Rep airs
and
Materials
usea
Test AR.er DC- Closed Closed Tight a Opcaed at Opmod at nsid
Repair Tight Q nsid nsid
RP sid
The above is cerriised to be true. �/ e 5
Firm Name Q L -7 ! o � �i � � Certified Teste p� � c•.l �► "e (Af � yi yt pf
FirmAddrrs_S Po (�oK 7r7 -7 Cert. Testes No. P�oa; >S�as Date 3��(�`rc�
C�.xc h Q C�Y.. -�
Csauge # � j � �% 1� �
Date Iasi accuracy tested J % ��
White - Customers Copy Yellow -City Copy Pink - Tester's Copy