2012_0316 (2)CHECK �DNEa
IiZRIGAZ'ION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION A.SSEIVIBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: L. �.? �!/ G'' (' � -� l- S�.. -�/
PWS I.D. #
LOCATION OF SERVICE: �9Id � t J r � c? vt. ci
The bzcckllrnv prevention assembly detailed below has been tcated and maintained as reduired by TCEQ
regulations and is certified to be operating; ���ithin acceptable parameters.
TYPE OF ASSEMBLY
� Rcduc�i Pressure Principle Q Pressure Vacuimi Breaks
Double Check Valve � Atmosphere Vacuum Breaker
Maaufacturcr �'k� 7`s 5 S� �� ,.
Model ?dumber AAGO-7 r✓1 / Located At C��r�� G/� 5 'i l�-��
Serial Number !i a- � G `/�
REDUCED PRESSURE PRI?`�iCIPLE ASSEPriBLY PRESSURE VACLTCJM BRFarrFR
Double Check Valve Asseffibly
1st Chest: 2nd Cbeci: Relief Valve Air Inlet Check Valve
Initial Test DC- Closed �� Closed Tight � Opened at Opened at nsid
Tight �d Lcal.:cd �� 6 D nsid nsid
RP- nsid
��� C Did not Opca Q i r�t� -.� p
�F ��
and
Materials
used
lest Af%r DC- Closed Closed Tigbt a Opened at Opened at nsid
Repair Tight t? nsid nsid
RP sid
The above is certified to be true. S/cPs
Firm Name /1 //C�� -rte z/ r-. �� Cartifiod Tester � fi�C -r � {- i,e/ � +�• v� �-
Firm Address YC� i�c�c 7 9 '7 Cent Testa No. ]-� 1'f�� `/ `7'a5 Date �/lG` /�
WQ,� � � c c H.�
Clauge # 3.� �rj / Y� l
Date last accuracy tested .� / ��
White - Customers Copy Yellow -City Copy Pink - Tester's Copy