2012_0316 (4)CIILC�K �ONEe
IRRIGATION
D 011A ESTIC
FIKELINE
13ACI{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: � i ? `,� G'` ( -- ! � -- !_),� �.- t l
PWS I.D. #i (�
LOCATION OF SERVICE: � LI y iJl ✓ r cI e ✓y
The backllow prevention assembly detailed below• has been tested and maintained as required by TCEQ
regulations and is certified to he operating within acceptab]e parameters_
TYPE OF ASSEMBLY
o Reduced Pressure Principle Q Presstre Vacutmm Breaker
QC% Double Check Valve o Atmosphere Vacuum Breaker
Manufacutcer h.�:3"7 S Size _ ����
Model Number �(7 7 �'v) �- Located At _ UQ V L ' �� � ��'� e % ,�,
Serial Number � t''7 � � /
The above is cctificd to be true, l�-P�j
Firm Name �!" ?r o,✓ � � � .i < Certified Tester M \) (nJe -� -. e- W c� ✓� ✓t �' �
Firm Address 1�`,'U1 6 a yc '�rj `% Ccrt Tester No. Rj r oc>en �'�� i Date 3��6�/v2
w G��V1 F C: ✓1i�
gauge # 3� �%ci /3
Date last accuracy tested � � /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEI4IBLY
___
(PRESSURE v�,C[TiJ1�f BR>r'aK�R
Double Check Valve Assembly
1st Checl:
2nd Cbeci: Relief Valve
Air Inlet Chec3c Valve
Initial Tat
DC- Closed %O
Closed Tight � Openea at
Opened at nsid
Tight R
Leaked � _a � asid
nsid
RP- nsid
I -caked G'
Did not Opea Q Leaic�ci Q
Rep airs
and
Materials
Used
Test After
DC- Closed
Closed Tight o Opcaed at
Opened at nsid
Repair
Tight a
nsid
nsid
RP std
The above is cctificd to be true, l�-P�j
Firm Name �!" ?r o,✓ � � � .i < Certified Tester M \) (nJe -� -. e- W c� ✓� ✓t �' �
Firm Address 1�`,'U1 6 a yc '�rj `% Ccrt Tester No. Rj r oc>en �'�� i Date 3��6�/v2
w G��V1 F C: ✓1i�
gauge # 3� �%ci /3
Date last accuracy tested � � /�
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy