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2013_0708 (4)
CHECK ONE: IRRIGATION X DOMESTIC FIRELINE BACKF'LOW PREVENTION ASSEMBLY TEST AND MAIN17 NANCE REPORT DAME OF PWS: L 1 ?'l C? F ['c,�T /t PWS I.D. 4E LOCATION OF SERVICE: &' f3 6 1 L -10 2 The backflmv prevention assembly detailed below has been tested and maintained as required by TCEQ re�.'ulations and is certifwd to be operating within acceptable parameters. ❑ Reduced Pressure 'Principle le IDouble Check Valve Manufacturer &b6o Model Number 9510 Serial Number C011'7L h#O/ TYPE OF ASSENIDLY El Pressure Vacuum Breaker ❑ Atmosphere Vacuum Brea}:er Size 8 , r Located At yau The above is certifier) to be true. Firm Name fkiiui Lu En Firm Address Pt � y -, y }X „7� (7 -y Gauge # —2L LL i i15 Date last accuracy tested ^�2 Certified Tester 1/X(111 Ai-) _ro rJ Ceit Tester No. "Z Ci01C6 i Date White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Waive Assembly Relief Valve Air Inlet Check Valve Ist Check 2nd Check Initial Test DC-Closed �'D Tight RP- „_,__.,psid Closed Tight je( Leaked Z 8 Opened at -psi Opened at ^, osid psid Leaked c Did not Open D Leaked O Repairs f and i Materials Used Test After Repair DC- Closed Tight o Closed Tight © Opened at psid Opened at sid _psid ( RP sid The above is certifier) to be true. Firm Name fkiiui Lu En Firm Address Pt � y -, y }X „7� (7 -y Gauge # —2L LL i i15 Date last accuracy tested ^�2 Certified Tester 1/X(111 Ai-) _ro rJ Ceit Tester No. "Z Ci01C6 i Date White - Customer's Copy Yellow - City Copy Pink - Tester's Copy