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2012_0312 (2)cllECx oNE: IRRIGATION DOMESTIC FIKELINE /V� BACKFi.OW PREVENTION ASSEMBLY TEST' AND MAINTENANCE REPORT NAME OF PWS: L / ? `� G'' F' [� c> !7 f! r / 1 PWS I.D. # LOCATION OF SERVICE: �d� � �![ �.✓c {J { The backflow prevention assembly detailed below has been tasted and maintained as required by TCEQ regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C7 Reduced Pressurt Principle © Pressure Vanrt�*+ Breaker D/o-urble Checl: Valve o Atmosphere Vacuum Breaker I�ianufacturer �/� � T 5 Size Model Number % © c( Located At S � � �G:C.!L Serial Number / � S 3 �� g White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACU'LTM BRF'arrFR Double Check Valve Assembly 1st Check 2nd Checi: RPItP{ Valve Air Inlet Cbeck Valve Initial Tcst DC- Clos«3 Closed Tight �ij Opened at Opened at osid Tight t*• � � Leaked �- �/ C7 osid osid RP- osid Leaked G' Did noc Opea Q Leaked o Repairs and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at osid Repair Tight a osid osid RP sid The above is certified to be true_ Firm Name �L � � y �i r'. !e Certified Testa llE - �- Firm Address PO (3 o x ? g � Cert_ Tester No. �00�>9 s/ a s Date 3 % »�/ o� (,�Q. >c c La G C' w -c Gauge # 3.��t !g llate last accuracy tested) � // White - Customer`s Copy Yellow -City Copy Pink - Tester's Copy